What medications are used to manage hemorrhagic stroke?

Management of Hemorrhagic Stroke: Medication Approaches

The primary medications used in hemorrhagic stroke management include blood pressure-lowering agents, osmotherapy for cerebral edema, anticonvulsants for seizures, and nimodipine for prevention of vasospasm in subarachnoid hemorrhage. 1

Blood Pressure Management

Blood pressure control is a cornerstone of hemorrhagic stroke management:

• Initial BP targets: Mean arterial pressure should be maintained below 130 mmHg in patients with a history of hypertension 1
• Medication options:
  • Intravenous labetalol, nicardipine, or clevidipine for rapid BP control
  • Avoid cerebral vasodilators as they may exacerbate raised intracranial pressure 1
  • Long-term management: Perindopril plus indapamide has shown a 50% reduction in recurrent ICH risk 1

Important considerations:

• BP lowering should be cautious (no more than 10-20% reduction initially) to avoid cerebral hypoperfusion 1
• Target SBP <130 mmHg for long-term secondary prevention 1

Management of Cerebral Edema

Cerebral edema is a common complication requiring prompt treatment:

• Osmotherapy: Mannitol or hypertonic saline for patients with deteriorating condition due to increased intracranial pressure 1
• Avoid corticosteroids: Not recommended for management of cerebral edema following stroke (Grade A recommendation) 1
• Fluid management: Mild restriction of fluids; avoid hypo-osmolar fluids like 5% dextrose which may worsen edema 1
• Positioning: Elevate head of bed by 20-30 degrees to help venous drainage 1

Seizure Management

Seizures occur in 4-43% of stroke patients and require appropriate treatment:

• Acute seizure management: Standard anticonvulsants (levetiracetam, phenytoin, valproate)
• Prophylactic anticonvulsants: Not recommended for patients who have had stroke but not seizures (Grade C recommendation) 1
• Status epilepticus: Requires aggressive treatment as it can be life-threatening 1

Specific Medications for Subarachnoid Hemorrhage

For subarachnoid hemorrhage specifically:

• Nimodipine: 60 mg orally every 4 hours for 21 consecutive days, starting within 96 hours of onset 2
  • Reduces severity of neurological deficits resulting from vasospasm
  • If patient cannot swallow, extract contents of capsule and administer via nasogastric tube
  • Never administer intravenously (can cause significant hypotension) 2

Reversal of Anticoagulation

For patients on anticoagulants who develop hemorrhagic stroke:

• Vitamin K antagonists: Rapid reversal with prothrombin complex concentrate or fresh frozen plasma plus vitamin K 1
• Direct oral anticoagulants: Specific reversal agents when available (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1

Experimental Treatments

Several treatments remain experimental:

• Hemostatic therapy: Recombinant Factor VIIa is not recommended outside clinical trials 1
• Tranexamic acid: Currently being investigated in clinical trials for hyperacute ICH 1
• Desmopressin: Under investigation for antiplatelet-associated ICH 1

Surgical Considerations

While not medications, surgical interventions often complement medical management:

• Cerebellar hemorrhage: Surgical evacuation recommended for cerebellar hemorrhages >3 cm causing brainstem compression or hydrocephalus 1
• Ventricular drainage: For treatment of hydrocephalus 1
• Minimally invasive surgery: Currently being investigated in clinical trials 3

Pitfalls to Avoid

1. Excessive BP reduction: May compromise cerebral perfusion and worsen ischemia
2. Corticosteroid use: Not effective for cerebral edema in hemorrhagic stroke
3. Prophylactic anticonvulsants: Not recommended without seizure history
4. Intravenous administration of nimodipine: Can cause dangerous hypotension
5. Delaying BP control: Should be initiated promptly, even in ED setting while awaiting ICU transfer 1

Early, aggressive, guideline-concordant care is recommended for patients with ICH who do not have advanced directives specifying otherwise, as current prognostic models may be biased by early withdrawal of care 1.