What are the latest management strategies for hemorrhagic stroke?

Latest Management of Hemorrhagic Stroke

Hemorrhagic stroke requires immediate treatment in specialized stroke units with rapid assessment, blood pressure control, and consideration for surgical intervention when appropriate to improve patient outcomes.

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, 2
• Conduct neurological examination using standardized scales such as the National Institutes of Health Stroke Scale (NIHSS) 1
• Obtain immediate neuroimaging (CT or MRI) to confirm diagnosis, location, and extent of hemorrhage 1, 3
• 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, 3

Blood Pressure Management

• Monitor blood pressure every 15 minutes until stabilized 1
• For patients with systolic blood pressure between 150-220 mmHg without contraindications, acute lowering of systolic BP to 140 mmHg is safe and can improve functional outcomes 1, 3
• Use intravenous antihypertensive agents with short half-lives for precise control 2
• After correcting hypovolemia or excess sedation, manage hypotension with small boluses of an α-agonist followed by an infusion 2

Management of Coagulopathy

• Rapidly reverse anticoagulation in patients on anticoagulant therapy 2
• For patients on warfarin with elevated INR, administer prothrombin complex concentrate plus intravenous vitamin K 1, 2
• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1
• Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of hematoma 4

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to help venous drainage 2
• Treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 2
• For patients with large ICH (volume > 30 cubic centimeters) or symptomatic perihematomal edema, maintain serum sodium level at 140-150 mEq/L for 7-10 days 4
• Consider osmotherapy (mannitol or hypertonic saline) for patients whose condition is deteriorating due to increased intracranial pressure 2, 4
• Hypertonic saline should be administered via central line as continuous infusion (3%) or bolus (23.4%) 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 should undergo surgical removal of the hemorrhage as soon as possible 1, 3
• Consider early surgery for patients with a Glasgow Coma Scale score 9-12 3
• Ventriculostomy is indicated for patients with severe intraventricular hemorrhage, hydrocephalus, or elevated ICP 4
• Minimally invasive surgical approaches may be beneficial for selected patients 5, 6

Prevention of Complications

• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1, 3
• Start subcutaneous unfractionated heparin in stable patients within 48 hours of admission 4
• Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1
• Avoid corticosteroids as they have not shown benefit 3
• There is no benefit for seizure prophylaxis, but treat seizures if they occur 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, 3
• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours 1
• Monitor for early deterioration, which is common in the first few hours after ICH onset 1
• Watch for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome 1, 7

Emerging Approaches

• Research is ongoing into ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury 6
• Local fibrinolysis combined with external ventricular drainage may be beneficial for patients with intraventricular hemorrhage 5
• Targeting neuroinflammation, improving energy metabolism, and inhibiting microtubule breakdown are being investigated as potential therapeutic options 8

Important Pitfalls to Avoid

• Do not delay imaging or treatment decisions while waiting for diagnostic test results 1
• Avoid transferring patients who are hypotensive and actively bleeding; control hemorrhage before transfer 2
• Do not use hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 2
• Avoid permissive hypotension during resuscitation of patients with traumatic brain injury 2
• Be vigilant for progression of hemorrhagic stroke, which can occur in acute, subacute, and chronic phases 7