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Despite the complexity of different conditions that result into brain bleeds, the acute presentation and diagnosis are relatively straightforward. Most patients present with a severe headache, one-sided weakness, sensory or coordination deficit, speech, vision or gait disturbances. It is more common for brain bleeds to cause quick decrease in level of consciousness and coma when compared to ischemic strokes. In patients presenting with any of these conditions, a computerized tomography (CT) scan of the brain is the gold standard to detect fresh, acute brain bleeds. In select situations such as patients with a sudden very severe headache ("worst headache of life"), a spinal tap (lumbar puncture) might be needed to rule out a subarachnoid hemorrhage even if the head CT was negative. 

Brain MRI is very sensitive to show both acute and old/chronic ischemic strokes as well as old/chronic blood products that can help diagnose the cause or mechanism of the stroke. MRI is more sensitive than CT to detect all types of non-hemorrhagic brain pathologies. Brain MRI is the only modality that can show microbleeds and superficial siderosis, important hemorrhagic markers discussed in different sections of this text. 

A simple diagram of first line tests to diagnose the potential cause of hemorrhagic stroke (IPH) is provided below but physicians indeed perform appropriate amount of testing based on the individual patient's needs.

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