How to manage orthostatic hypotension in patients with intracranial bleeding?

From the Guidelines

Orthostatic hypotension in patients with intracranial bleeding should be managed with caution, prioritizing non-pharmacological interventions to maintain cerebral perfusion while minimizing the risk of bleeding exacerbation. When managing orthostatic hypotension in these patients, it is crucial to consider the potential impact on morbidity, mortality, and quality of life. The primary goal is to prevent further complications from the intracranial bleeding while addressing the orthostatic hypotension.

Non-Pharmacological Interventions

Non-pharmacological measures are the first line of treatment, as they pose less risk of exacerbating the intracranial bleeding. These include:

• Gradual position changes to avoid sudden drops in blood pressure
• Use of compression stockings and abdominal binders to improve venous return
• Adequate hydration with isotonic fluids, such as normal saline, to maintain euvolemia
• Patient education on slow position changes and the use of physical counter-manoeuvres like leg-crossing, stooping, squatting, and tensing muscles 1

Pharmacological Interventions

If non-pharmacological measures are insufficient, pharmacological options can be considered cautiously. The choice of medication should be based on the patient's specific condition and the potential risks and benefits.

• Midodrine, a peripheral selective α1-adrenergic agonist, is often considered due to its pressor effect without significantly affecting cerebral blood flow. However, its use must be tailored to the individual, starting at lower doses (e.g., 2.5-5 mg three times daily) and avoiding its use several hours before planned recumbency, especially in patients with supine hypertension 1.
• Other medications like fludrocortisone may be used for persistent symptoms but require careful monitoring for fluid retention and hypertension.

Monitoring and Goals

Continuous hemodynamic monitoring is essential, particularly during the acute phase of intracranial bleeding. Blood pressure goals should be individualized, aiming for a systolic blood pressure that maintains cerebral perfusion pressure while limiting the risk of hematoma expansion. Typically, this target is between 140-160 mmHg. As the patient stabilizes and mobilizes, interventions can be gradually weaned.

The management of orthostatic hypotension in patients with intracranial bleeding is complex and requires a balanced approach to prevent further neurological deterioration while addressing the hypotension. Given the potential for significant morbidity and mortality, careful consideration of the most recent and highest quality evidence is crucial in guiding treatment decisions 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations The indication is based on midodrine's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit.

Management of Orthostatic Hypotension in Patients with Intracranial Bleeding: To manage orthostatic hypotension in patients with intracranial bleeding, midodrine can be considered as a treatment option. However, it is crucial to carefully evaluate the potential for supine and sitting hypertension at the beginning of midodrine therapy.

• The patient should be cautioned to report symptoms of supine hypertension immediately.
• Blood pressure should be monitored carefully when midodrine is used concomitantly with other agents that cause vasoconstriction.
• Midodrine should be used with caution in patients with urinary retention problems, diabetes, and a history of visual problems.
• The dosage of midodrine should be adjusted according to the patient's response, and renal function should be assessed prior to initial use. 2 2 2

From the Research

Orthostatic Hypotension Management

Orthostatic hypotension is a condition characterized by a significant drop in blood pressure when standing up from sitting or lying down, which can lead to symptoms such as dizziness, lightheadedness, and fainting. In patients with intracranial bleeding, managing orthostatic hypotension is crucial to prevent further complications.

Causes and Risk Factors

• Intracranial bleeding can cause orthostatic hypotension due to the disruption of autonomic nervous system function, which regulates blood pressure and heart rate 3.
• Other risk factors for orthostatic hypotension include diabetes, older age, and certain medications 3.

Treatment Options

• Midodrine, an alpha-1 adrenergic agonist, is a commonly used medication for treating orthostatic hypotension, as it increases blood pressure and improves symptoms 4, 5.
• Fludrocortisone, a mineralocorticoid, can also be used to treat orthostatic hypotension, but its long-term effects are concerning, and it may be associated with a higher risk of hospitalizations compared to midodrine 6, 7.
• Non-pharmacological strategies, such as increasing fluid and salt intake, wearing compression garments, and avoiding environments that exacerbate symptoms, can also be effective in managing orthostatic hypotension 3.

Management Strategies

• Initial treatment should focus on addressing the underlying cause of orthostatic hypotension and adjusting potentially causative medications 3.
• Patients with intracranial bleeding should be closely monitored for signs and symptoms of orthostatic hypotension, and treatment should be tailored to their individual needs 3.
• A multidisciplinary approach, involving healthcare professionals from various specialties, may be necessary to manage orthostatic hypotension in patients with complex medical conditions like intracranial bleeding.