What is the treatment for a hemorrhagic stroke?

Treatment of Hemorrhagic Stroke

The management of hemorrhagic stroke requires immediate medical attention with a focus on stabilizing the patient, controlling blood pressure, preventing hematoma expansion, managing intracranial pressure, and addressing the underlying cause to improve mortality and functional outcomes.

Initial Assessment and Stabilization

• Patients with hemorrhagic stroke must be treated as a medical emergency and evaluated immediately by physicians with expertise in hyperacute stroke management 1

• Initial clinical assessment should include:

  • Rapid evaluation of airway, breathing, and circulation 1
  • Neurological examination using standardized scales (NIHSS for awake patients, GCS for obtunded or comatose patients) 1
  • Assessment of vital signs including heart rate, blood pressure, temperature, and oxygen saturation 1

• Immediate neuroimaging is essential:

  • Non-contrast CT or MRI should be performed immediately to confirm diagnosis, location, and extent of hemorrhage 1
  • CT angiography, MR angiography, or catheter angiography is recommended to exclude underlying lesions such as aneurysms or arteriovenous malformations 1

Blood Pressure Management

• Blood pressure should be assessed on initial arrival and every 15 minutes until stabilized 1
• Blood pressure targets may be challenging to achieve and require careful monitoring 1
• For patients with ICH, aggressive blood pressure management is recommended:
  • Elevated blood pressure is common in ICH patients, with >70% having systolic BP above 140 mmHg and about 20% above 180 mmHg at presentation 2
  • Hypertension is associated with hematoma expansion and poor outcomes 1

Surgical Interventions

• Neurosurgical interventions may be necessary for:

  • Hematoma evacuation
  • External ventricular drainage
  • Invasive monitoring and treatment of intracranial pressure 1

• For patients with intraventricular hemorrhage (IVH):

  • External ventricular drainage (EVD) with intraventricular fibrinolysis (IVF) has shown benefits:
    • Decreased mortality (22.4% vs. 40.9% without IVF) 1
    • Improved functional outcomes (47.2% vs. 38.3% without IVF) 1
    • Reduced catheter occlusion rates (10.6% vs. 37.3% without IVF) 1

• For hemorrhagic moyamoya angiopathy:

  • Direct or combined bypass surgery is reasonable, especially for patients with posterior hemorrhage to prevent recurrences 1

Management of Coagulopathy

• Evaluation should include questions about anticoagulant therapy, measurement of platelet count, partial thromboplastin time (PTT), and INR 1
• Patients with intracranial bleeding during oral anticoagulation should be treated with fresh frozen plasma or prothrombin complex concentrates 1

Ongoing Monitoring and Care

• Continuous automated monitoring of physiological parameters is essential:

  • Oxygen saturation
  • Arterial blood pressure
  • Heart rhythm and ECG
  • Body temperature
  • Blood glucose 1

• Close neurological monitoring using validated scales should be conducted at baseline and repeated at least hourly for the first 24 hours 1

• Patients should be assessed for clinical signs of increased intracranial pressure 1

Prevention of Complications

• Specialized nursing care should focus on:

  • Careful positioning and handling of patients
  • Pressure-area risk evaluation
  • Neurological monitoring
  • Fluid balance assessment
  • Monitoring of excretions and body temperature
  • Assessment of dysphagia 1

• These measures aim to prevent complications like aspiration pneumonia, deep venous thrombosis, pressure sores, and dehydration 1

Secondary Prevention

• Hypertension management is crucial as it is a significant risk factor for both hemorrhagic and ischemic stroke recurrence (OR 1.87 for hemorrhagic stroke) 3
• Antiplatelet therapy may decrease the risk of hemorrhagic stroke recurrence (OR 0.53) but does not appear to decrease the risk of ischemic stroke recurrence in patients with prior ICH 3

Emerging Approaches

• Current research is exploring novel approaches for ICH management:

  • Prognostic biomarkers and primary prevention based on disease pathobiology
  • Ultra-early hemostatic therapy
  • Minimally invasive surgery
  • Perihematomal protection against inflammatory brain injury 4

• Targeting neuroinflammation, improving energy metabolism, inhibiting microtubule breakdown, and stimulating axonal growth and regeneration are being investigated as therapeutic options 5

Important Considerations and Pitfalls

• Early neurologic deterioration is common in hemorrhagic stroke:

  • Within the first hour of presentation, 15% of patients demonstrate a decrease in GCS of two or more points 1
  • The risk for early deterioration underscores the need for aggressive early management 1

• Hematoma expansion is a predictor of clinical deterioration and increased morbidity and mortality 1

• Risk factors for hematoma expansion include:

  • Presence of contrast extravasation ("spot sign")
  • Early presentation to medical attention
  • Anticoagulation use
  • Initial hematoma volume 1

• Despite numerous trials investigating optimal medical and surgical management of ICH, there has been no clear improvement in survival and functional outcomes, highlighting the need for continued research 6