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Fig. 6. These axial images from a noncontrast head CT scan reveal a wedge-shaped region of low attenuation in the right frontal lobe with a focal intraparenchymal hemorrhage at the superior margin. These images, consistent with a hemorrhagic transformation of a subacute infarct, were taken from a 65-year-old woman who had a history of TIAs and who presented with a right facial droop and slurred speech.
after the onset of symptoms. Although no clinician would intentionally treat a stroke mimic with thrombolytics, a recent small observational study showed no hemorrhagic complications in these patients [67]. The urgency of assessment and treatment implicit in the golden hour model of trauma care has been adapted successfully to stroke. Guidelines for optimal speed in treatment were established by the National Institute for Neurological Disorders and Stroke (NINDS) Study Group in 1997. The recommendations suggest an initial physician evaluation within 10 minutes of ED arrival, noncontrast CT scan within 25 minutes, radiologist interpretation within 45 minutes, and the administration of thrombolytics, if appropriate, within 1 hour [68]. Such a stringent timeline is only feasible with firm commitment from the departments of emergency medicine, radiology, and neurology within a given institution. The incidence of spontaneous intracerebral hemorrhage (ICH) ranges from 10 to 20 cases per 100,000 population and is associated directly with advancing age [69]. Chronic hypertension and amyloid angiopathy, both more common in the elderly population, increase the likelihood of bleeding. Hemorrhagic strokes, although less frequent than ischemic events, are more deadly and have fewer effective therapeutic options. One-month mortality ranges from 35% to 52% [70]. Early progression of hemorrhage is common and linked with abrupt clinical decline. In a prospective study, Brott and colleagues found that 38% of ICH patients imaged within 3 hours of symptom onset developed significant hematoma expansion within 20 hours. Nearly 70% of these patients (26% of