What is the initial workup for a hemorrhagic stroke within the first hour?

From the Guidelines

For a hemorrhagic stroke workup before the 1-hour mark, immediately obtain a non-contrast CT scan of the brain, which is the gold standard for identifying intracranial hemorrhage, as recommended by the most recent guidelines 1.

Initial Workup

The initial workup for a hemorrhagic stroke within the first hour should prioritize the following steps:

• Obtain a non-contrast CT scan of the brain to identify intracranial hemorrhage
• Order stat laboratory tests, including:
  • Complete blood count
  • Coagulation studies (PT/INR, PTT)
  • Basic metabolic panel
  • Type and cross for potential blood products
• Check vital signs and maintain blood pressure control, typically keeping systolic BP below 140-160 mmHg using IV agents like nicardipine (5-15 mg/hr) or labetalol (10-20 mg boluses) 1

Anticoagulation Reversal

Reverse any anticoagulation immediately:

• For warfarin, administer prothrombin complex concentrate (25-50 units/kg) and vitamin K (10 mg IV)
• For DOACs, use specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors

Airway Management

Secure the airway if GCS is below 8 or declining

Consultation

Consult neurosurgery and neurocritical care teams promptly, as recommended by guidelines for acute stroke management 1

This rapid approach is critical as hemorrhagic strokes have high early mortality, and controlling bleeding within the first hour can significantly improve outcomes by preventing hematoma expansion, which occurs most frequently in the early phase after symptom onset 1.

From the Research

Initial Workup for Hemorrhagic Stroke

The initial workup for a hemorrhagic stroke within the first hour involves several key steps:

• Identification of hemorrhage using a noncontrast head CT, which is the most common initial neuroimaging study 2
• Assessment of the patient's medical history, neurologic examination, and laboratory studies to guide further management 2
• Blood pressure control, with optimal management of blood pressure in the acute phase being controversial, but high blood pressure should still be treated according to guidelines 3
• Consideration of the patient's use of oral anticoagulants, as these patients have a higher risk of intracerebral hemorrhage and higher mortality rates 2

Neuroimaging and Blood Pressure Management

Neuroimaging studies are essential for the identification of hemorrhagic stroke, determination of the underlying etiology, and treatment of acute complications 2

• A noncontrast head CT is typically the first neuroimaging study performed, followed by further studies as needed to guide management 2
• Blood pressure management is critical, with studies suggesting that lowering systolic blood pressure to 160 mmHg or less using nicardipine may be well tolerated and feasible for acute intracerebral hemorrhage 4

Nursing Care and Management

Nurses play a critical role in the identification, assessment, management, and coordination of care for patients with hemorrhagic stroke 5

• The first 24 hours are critical for stroke care, and nurses must be able to quickly identify and assess patients with stroke, as well as coordinate care and management 5
• The initial workup and management of hemorrhagic stroke require a multidisciplinary approach, with nurses working closely with other healthcare professionals to provide optimal care 5