What is the immediate management of a patient presenting with a hemorrhagic stroke?

Immediate Management of Hemorrhagic Stroke

The immediate management of hemorrhagic stroke requires rapid assessment, stabilization, blood pressure control, reversal of coagulopathy, and consideration for surgical intervention to reduce mortality and improve outcomes. 1

Initial Assessment and Stabilization

• Treat hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with expertise in hyperacute stroke management 1
• Perform rapid assessment of airway, breathing, and circulation (ABCs) immediately upon arrival 1
• Conduct neurological examination to determine focal deficits and assess stroke severity using standardized scales such as the National Institutes of Health Stroke Scale (NIHSS) 1
• Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage 1, 2
• Order urgent blood work including complete blood count, coagulation status (INR, aPTT), and blood glucose 1
• Evaluate medication history, particularly focusing on anticoagulant or antiplatelet therapy 1
• Consider vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 1

Blood Pressure Management

• Monitor blood pressure every 15 minutes until stabilized 1
• For patients with systolic blood pressure between 150-220 mmHg, acute lowering to 140 mmHg is safe and can improve functional outcomes 1, 3
• Avoid excessive blood pressure reduction below 140 mmHg as this may increase risk of renal complications without improving functional outcomes 3
• Use small boluses of labetalol for hypertension management 4
• After correcting hypovolemia or excess sedation, manage hypotension with small boluses of an α-agonist followed by an infusion (e.g., metaraminol or noradrenaline via central venous catheter) 4

Management of Coagulopathy

• Rapidly reverse anticoagulation while limiting fluid volumes 4
• For patients on warfarin with elevated INR, administer prothrombin complex concentrate (not fresh frozen plasma) plus intravenous vitamin K 4, 1
• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1

Fluid Management

• Use isotonic fluids (0.9% saline) to maintain hydration while preventing volume overload 4
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 4
• Avoid Ringer's lactate, Ringer's acetate, and gelatins as they are hypotonic in terms of real osmolality 4
• Do not use albumin or other synthetic colloids in early management 4

Seizure Management

• Treat new-onset seizures occurring within 24 hours of stroke onset with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited 1
• Single, self-limiting seizures at onset or within 24 hours should not receive long-term anticonvulsant medications 1
• Recurrent seizures should be treated as with any other acute neurological condition 4
• Prophylactic administration of anticonvulsants is not recommended 4

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to help venous drainage 4
• Treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 4
• Avoid antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 4
• Consider osmotherapy for patients whose condition is deteriorating due to increased intracranial pressure 4

Surgical Considerations

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 1
• 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
• Consider surgical decompression and evacuation of large cerebellar infarctions leading to brain stem compression and hydrocephalus 4

Monitoring and Nursing Care

• Provide initial monitoring and management in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1
• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1
• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1
• Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1

Important Pitfalls to Avoid

• Be vigilant for early deterioration, which is common in the first few hours after ICH onset (>20% of patients experience a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation) 1
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome 1, 5
• Avoid delaying imaging or treatment decisions while waiting for diagnostic test results 1
• Do not transfer patients who are hypotensive and actively bleeding; control hemorrhage before transfer 4
• Avoid permissive hypotension during resuscitation of multiply-injured patients with traumatic brain injury except in exceptional circumstances 4