Hemorrhagic strokes love to show up as “sudden, severe, and catastrophic” on vignettes—and they’re easy points on Step exams if you can see the pattern quickly. This is a fast, shareable visual hack for intracerebral hemorrhage (ICH) vs subarachnoid hemorrhage (SAH), plus the highest-yield associations and next steps.
The visual hack (2 buckets): IN the brain vs SUBarachnoid space
Bucket 1: ICH = “IN” trap
Think: blood trapped in the brain tissue → focal deficits + mass effect.
One-liner: ICH = focal neuro deficits + ↑ICP (often from HTN/amyloid) with a hyperdense bleed on CT.
Mental picture: A deep “bruise” inside the brain that pushes on nearby structures.
Bucket 2: SAH = “Surface splash”
Think: blood splashed on the brain surface (subarachnoid space) → meningismus + thunderclap headache.
One-liner: SAH = thunderclap headache ± meningismus (often aneurysm) with blood in cisterns/sulci on CT.
Mental picture: Blood coating the gyri and collecting in basal cisterns.
Mnemonics you can recall under time pressure
ICH: “HARD”
- Hypertension (Charcot–Bouchard microaneurysms; deep bleeds)
- Amyloid angiopathy (lobar bleeds in elderly)
- Rupture of small penetrating arteries (basal ganglia, thalamus, pons, cerebellum)
- Deficits + Deterioration (mass effect, herniation risk)
SAH: “SPLASH”
- Sudden severe (“worst headache of my life”)
- Photophobia/meningismus
- Loss of consciousness can happen
- Aneurysm (berry) at circle of Willis
- Subarachnoid blood in sulci/cisterns
- Hydrocephalus + vasospasm complications
Quick comparison table (exam-friendly)
| Feature | ICH | SAH |
|---|---|---|
| Hallmark symptom | Focal deficits + headache/vomiting possible | Thunderclap headache ± neck stiffness |
| Neuro exam | Often focal (hemiparesis, gaze preference, etc.) | May be nonfocal early; meningismus common |
| Common causes | HTN, amyloid angiopathy, anticoagulation, AVM | Berry aneurysm, AVM |
| Best initial test | Noncontrast CT head | Noncontrast CT head |
| If CT negative but suspicion high | Consider other causes; MRI sometimes | LP (xanthochromia) if CT negative and still high suspicion |
| Key complications | Herniation, intraventricular extension | Vasospasm, hydrocephalus, rebleed |
| Classic board association | Deep bleed = HTN | Thunderclap = aneurysm until proven otherwise |
High-yield: where the blood tends to be (ICH localization)
Hypertensive ICH = deep structures
Small penetrating arteries rupture → classically:
- Basal ganglia (putamen) — most common
- Thalamus
- Pons
- Cerebellum
Step pearl: If you see HTN + acute focal deficits + deep hemorrhage, think Charcot–Bouchard microaneurysms.
Amyloid angiopathy = lobar hemorrhage
- Elderly patient
- Lobar cortical hemorrhages (often recurrent)
- Not the classic deep HTN locations
Step pearl: “Older adult with recurrent lobar hemorrhages” → cerebral amyloid angiopathy.
High-yield: SAH sources + classic risks
Berry aneurysm basics
- Saccular aneurysm at branch points in the Circle of Willis
- Common sites: anterior communicating artery, posterior communicating artery, MCA bifurcation
Major risk associations:
- ADPKD
- Ehlers-Danlos (vascular type)
- Family history, smoking, HTN
What SAH looks like clinically
- Thunderclap headache: maximal intensity within seconds to minutes
- Meningismus: neck stiffness, photophobia
- ± nausea/vomiting, transient LOC
Step pearl: “Worst headache of life” is SAH until proven otherwise.
Imaging & diagnosis: the Step-style algorithm
First move for both: Noncontrast CT head
- Fast and great for acute blood (hyperdense)
If SAH suspected and CT is negative
- Lumbar puncture can show:
- Xanthochromia (yellow CSF from bilirubin)
- RBCs that don’t clear between tubes (less emphasized than xanthochromia on exams)
High-yield nuance: Xanthochromia supports SAH when CT misses it (especially if time has passed).
Complications you must know (especially SAH)
1) Vasospasm (days later)
- Typically 3–14 days after SAH
- Causes delayed ischemic deficits
Prevention/management association: Nimodipine is used to reduce risk of ischemic deficits from vasospasm.
2) Hydrocephalus
- Blood can clog arachnoid granulations → impaired CSF resorption → communicating hydrocephalus
- Can cause worsening headache, nausea/vomiting, decreased level of consciousness
3) Rebleeding
- Early rebleed is devastating; definitive aneurysm management is key (clipping/coiling—often treated as “secure the aneurysm” on exams)
Management pearls (what Step expects you to say)
ICH (broad strokes)
- Stabilize ABCs, manage blood pressure (institution-specific targets)
- Reverse anticoagulation if present
- Manage ↑ICP if needed
- Neurosurgical evaluation depending on size/location (cerebellar hemorrhage can be particularly dangerous due to brainstem compression)
SAH (broad strokes)
- Stabilize; treat as neurosurgical emergency
- Secure aneurysm (coil/clip)
- Nimodipine for vasospasm risk
- Monitor for hydrocephalus and rebleed
“Shareable” one-glance summary (save this)
- ICH = INjury inside brain tissue → focal deficits + mass effect, deep bleeds = HTN
- SAH = Surface splash → thunderclap headache + meningismus, worry about berry aneurysm, prevent vasospasm with nimodipine
Rapid-fire vignette cues (USMLE-style)
- Deep hemorrhage + chronic HTN → Charcot–Bouchard microaneurysm → ICH
- Elderly + recurrent lobar bleeds → amyloid angiopathy
- Worst headache of life + neck stiffness → SAH
- SAH + days later new neuro deficits → vasospasm (nimodipine association)
- CT negative but classic thunderclap → LP for xanthochromia