What is the initial management for a patient presenting with hemorrhagic stroke?

Initial Management of Hemorrhagic Stroke

Patients with intracerebral hemorrhage (ICH) must be treated as a medical emergency with immediate evaluation by physicians with expertise in hyperacute stroke management. 1

Initial Assessment and Stabilization

• Rapid initial evaluation of airway, breathing, and circulation (ABCs) should be performed immediately upon arrival 1
• Neurological examination should be conducted to determine focal deficits and assess stroke severity using standardized scales:
  • National Institutes of Health Stroke Scale (NIHSS) for awake or drowsy patients 1
  • Glasgow Coma Scale (GCS) for obtunded, semi or fully comatose patients 1
• Immediate neuroimaging with CT or MRI is mandatory to confirm diagnosis, location, and extent of hemorrhage 1
• Assessment of vital signs including heart rate, rhythm, blood pressure, temperature, oxygen saturation, and hydration status 1

Diagnostic Workup

• Urgent blood work should include 1:
  • Electrolytes
  • Random glucose
  • Complete blood count
  • Coagulation status (INR, aPTT)
  • Creatinine
• Evaluation should include questions about anticoagulant therapy and medication history 1
• In patients with confirmed acute ICH, vascular imaging (CT angiography, MR angiography, or catheter angiography) is recommended to exclude underlying lesions such as aneurysms or arteriovenous malformations 1
• Assessment for clinical signs of increased intracranial pressure 1

Blood Pressure Management

• Blood pressure should be assessed on initial arrival to the ED and every 15 minutes until stabilized 1
• For ICH patients presenting with systolic blood pressure between 150 and 220 mm Hg without contraindications to acute BP treatment, acute lowering of systolic BP to 140 mm Hg is safe and can improve functional outcomes 1
• Close blood pressure monitoring (every 30-60 minutes, or more frequently if above target) should continue for at least the first 24-48 hours 1

Management of Coagulopathy

• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1
• Patients whose INR is elevated due to vitamin K antagonists should have their medication withheld, receive therapy to replace vitamin K-dependent factors, correct the INR, and receive intravenous vitamin K 1

Seizure Management

• New onset seizures occurring immediately before or within 24 hours of stroke onset should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited 1
• A single, self-limiting seizure occurring at onset or within 24 hours should not be treated with long-term anticonvulsant medications 1
• Patients should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status 1

Monitoring and Nursing Care

• Initial monitoring and management should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1, 2
• A validated neurological scale should be conducted at baseline and repeated at least hourly for the first 24 hours, depending on patient stability 1
• Glucose should be monitored, and both hyperglycemia and hypoglycemia should be avoided 1

Surgical Considerations

• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible 1
• Neurosurgical consultation should be obtained promptly for evaluation of potential surgical interventions 1

Prevention of Complications

• Patients should have intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1
• A formal screening procedure for dysphagia should be performed before initiating oral intake to reduce the risk of pneumonia 1

Pitfalls and Caveats

• Early deterioration is common in the first few hours after ICH onset, with over 20% of patients experiencing a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation 1
• Hematoma expansion occurs in 30-40% of patients and is a predictor of poor outcome; risk factors include presence of contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume 1, 3
• Diagnostic tests should not delay imaging or treatment decisions 1
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 1