Ischemic Stroke and Spontaneous Intracerebral Hematoma

Panayiotis Mitsias

Troels Staehelin Jensen

HEADACHE IN ISCHEMIC STROKE AND SPONTANEOUS INTRACEREBRAL HEMATOMA

Definitions

International Headache Society (IHS) codes and diagnoses (23):

6.1.1 Headache attributed to ischemic stroke (cerebral infarction)

A. Any acute headache fulfilling criterion C.

B. Neurological signs and/or neuroimaging evidence of a recent ischemic stroke.

C. Headache develops simultaneously with or in very close temporal relation to signs or other evidence of ischemic stroke.

6.1.2 Headache attributed to transient ischemic attack (TIA)

A. Any acute headache fulfilling criteria C and D.

B. Focal neurologic deficit of ischemic origin lasting <24 hours.

C. Headache develops simultaneously with onset of focal deficit.

D. Headache resolves within 24 hours.

6.2.1 Headache attributed to spontaneous intracerebral hematoma

A. Any acute headache fulfilling criterion C.

B. Neurologic signs or neuroimaging evidence of a recent nontraumatic intracerebral hemorrhage.

C. Headache develops simultaneously with or in very close temporal relation to intracerebral hemorrhage.

WHO code and diagnosis: 44.81. Headache associated with other vascular disorders

Headache is one of the primary features of acute focal cerebrovascular disease. A well-known accompaniment of hemorrhagic stroke, especially subarachnoid hemorrhage, headache is an underemphasized symptom of ischemic stroke, because it is usually overshadowed by other more dramatic clinical manifestations, such as aphasia, hemiplegia, hemianopsia, or neglect.

Thomas Willis (1664) first recognized the relationship between headache and cerebrovascular disease in a patient with asymptomatic carotid artery (CA) occlusion who experienced severe headache ipsilateral to the patent CA (63). Extreme dilation in the patent CA circulation, secondary to collateral blood flow, was the postulated cause of headache (63). Three centuries later, Fisher reported the first comprehensive study of headaches associated with ischemic and hemorrhagic cerebrovascular disease (18). Several authors subsequently provided detailed, but often conflicting, data on the frequency, features, pathogenesis, and prognostic value of headache in acute cerebrovascular disease (6,14,16,17,21,27,30,32,36,40,42,45,51,52,60).

ISCHEMIC STROKE AND TRANSIENT ISCHEMIC ATTACKS

Epidemiology

There is wide variability in the reported frequency of headache at onset of ischemic stroke or TIA among studies, due to a variety of factors, including study design (retrospective vs. prospective), population studied (community vs. referral hospitals), type of ischemic event (TIA, minor or major stroke), and time interval from stroke onset to headache occurrence.

Prospective studies on the occurrence of headache in patients with TIA reveal an overall headache frequency of 16 to 36% (6,14,16,17,30,36,40,51) (Table 108-1), while in populations of patients with ischemic stroke, headache occurs in approximately 8 to 34% (6,14,17,21,27,30,32,45, 51,52,60) (Table 108-2). Overall, the frequency of headache at onset of ischemic stroke is significantly lower to
that associated with intraparenchymal hemorrhage (Table 108-3). However, headache frequency in patients with ischemic stroke may be underestimated when patients with language dysfunction, altered mental status, or other factors preventing reliable determination of a headache complaint are excluded. Also, most patients with severe sensory loss, memory loss, or pain asymbolia as part of the acute stroke syndrome may not report headache (18).

TABLE 108-1 Frequency of Headache in Transient Ischemic Attacks: Prospective Studies

*Study*	*Year*	*Headache Frequency (%)*
Medina et al. (40)	1975	21
Edmeads (14)	1979	24
Portenoy et al. (51)	1984	36
Loeb et al. (36)	1985	30
Koudstaal et al. (30)	1991	16
Arboix et al. (6)	1994	26
Ferro et al. (16)	1995	29

Factors Related to the Occurrence, or Not, of Headache at Onset of Ischemic Stroke

Studies have shown consistently that headache is more frequent in patients with vertebrobasilar territory ischemia as compared to anterior circulation involvement (6,17,27,30,32,34,44,60) (Table 108-4). Individual reports reveal that the following factors may be operant in the onset of headache with cerebral ischemia: female gender (27,51), underlying migraine (17,32,44,51), younger age (6,17,27,44,60), nonsmoking status (17,21,60), absence of hypertension (44), underlying diabetes mellitus (32), underlying ischemic heart disease (27,30,32), aCL immunoreactivity (44), and treatment with warfarin at the time of occurrence of the index stroke (44). It should be noted that these factors cannot be considered independent for the development of onset headache in ischemic stroke until multivariate confirmatory analyses are conducted.

TABLE 108-2 Frequency of Onset Headache in Acute Ischemic Stroke: Prospective Studies

*Study*	*Year*	*Headache Frequency (%)*
Mohr et al. (45)	1978	8
Edmeads (14)	1979	25
Portenoy et al. (51)	1984	29
Gorelick et al. (21)	1986	17
Koudstaal et al. (30)	1991	19
Vestergaard et al.(60)	1993	23
Jorgensen et al. (27)	1994	28
Arboix et al. (6)	1994	31
Kumral et al. (32)	1995	16
Ferro et al. (17)	1995	34
Rathore et al. (52)	2002	22

TABLE 108-3 Headache Frequency in Ischemic Stroke vs. Intraparenchymal Hemorrhage

*Study*	*Year*	*Ischemia (%)*	*Hemorrhage (%)*	p value
Mohr et al. (45)	1978	3-12	33
Portenoy et al. (51)	1984	29	57	<0.05
Gorelick et al. (21)	1986	17	55	0.0001
Vestergaard et al. (60)	1993	23	50
Jorgensen et al. (27)	1994	25	49	0.002
Arboix et al. (6)	1994	32	65	<0.0001
Kumral et al. (32)	1995	16	36	<0.001
Rathore et al. (52)	2002	22	55	0.001

Headache Characteristics

Intensity and Quality

The headache can be abrupt or gradual in onset (51). It is usually unilateral, focal, and of mild to moderate severity (6,21,60); rarely, it may be incapacitating (6,60). The character of the headache is nonspecific, described as either throbbing (17 to 54%) (6,51,60) or continuous and nonthrobbing (14 to 94%) (6,30,51). Stabbing or pulsating
character have also been reported (6). Frequently, the headache is accompanied by nausea (44%), vomiting (23%), and photophobia and phonophobia (25%) (60).

TABLE 108-4 Headache Frequency in Posterior vs. Anterior Circulation Ischemic Stroke

*Study*	*Year*	*Anterior (%)*	*Posterior (%)*	p value
Koudstaal et al. (30)	1991	13	27	<0.00003
Vestergaard et al. (60)	1993	23	46	0.02
Jorgensen et al. (27)	1994	26	37	0.007
Arboix et al. (6)	1994	26	59	<0.0001
Kumral et al. (32)	1995	14	29	<0.001
Ferro et al. (17)	1995	35	65	0.0002
Libman et al. (34)	2001	8.7	15	0.013

Headache severity is not related to the size of infarction or stroke location (6,27,60), but in general it is more severe with posterior circulation infarcts (30,60), and worse when it is located occipitally rather than frontally (60). The headache is usually worsened by coughing, bending, straining, or jarring the head, or following sublingual nitroglycerin (14,18). In contrast, digital compression of the superficial temporal artery on the side of the headache temporarily eases the discomfort (14).

Location

It is debated whether the location of headache provides useful information about the vascular site and mechanism in ischemic cerebrovascular disease. Fisher indicated that the lateralized headache of CA occlusion is usually located in the ipsilateral frontal and orbital regions, while the pain of MCA thrombosis affects the orbital and supraorbital area and that of MCA embolism the ipsilateral temple (18). Others (51) found that headache location did not vary with the type of vascular event and did not predict the location of stroke. Overall, the headache location cannot accurately predict the location of the ischemic event or the affected vessel (6,14,27,32,60), and as Edmeads stated, attempts to localize the infarct or the occluded vessel based on headache location is an exercise fraught with error (14).

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