What interventions are needed for acute hemorrhagic stroke?

Management of Acute Hemorrhagic Stroke

For acute hemorrhagic stroke, immediate assessment and stabilization of airway, breathing, and circulation followed by rapid neuroimaging, blood pressure control, management of coagulopathy, and consideration for surgical intervention are essential for improving patient outcomes. 1

Initial Assessment and Stabilization

• Immediate evaluation by physicians with expertise in hyperacute stroke management is crucial, as hemorrhagic stroke is a medical emergency 1
• Perform rapid assessment of airway, breathing, and circulation (ABCs) immediately upon arrival 1
• Conduct neurological examination using standardized scales such as the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and stroke severity 1
• Monitor neurological status (including Glasgow Coma Scale) and vital signs including pulse, blood pressure, temperature, oxygen saturation, and glucose regularly during the acute phase 2
• 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

Diagnostic Workup

• Immediate neuroimaging with CT or MRI is mandatory to confirm diagnosis, location, and extent of hemorrhage 1
• Urgent blood work should include complete blood count, coagulation status (INR, aPTT), and blood glucose 1
• Evaluate medication history with particular attention to anticoagulant therapy 1
• In 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
• Laboratory test results should be available on-site within 20 minutes after blood sampling 2

Blood Pressure Management

• Blood pressure should be assessed on initial arrival and every 15 minutes until stabilized 1
• For ICH patients with systolic blood pressure between 150-220 mmHg without contraindications to acute BP treatment, acute lowering of systolic BP to 140 mmHg is safe and can improve functional outcomes 1
• In ICH patients with a history of hypertension, mean arterial pressure should be maintained below 130 mmHg 2
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 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
• Rapid reversal of vitamin K antagonists is essential in hemorrhagic stroke 3

Seizure Management

• New onset seizures occurring 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

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
• A validated neurological scale should be conducted at baseline and repeated at least hourly for the first 24 hours, depending on patient stability 1
• 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

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
• Surgical evacuation may be undertaken for cerebellar hemisphere hematomas >3 cm diameter in selected patients 2
• For supratentorial hemorrhage, the routine use of surgery is not recommended but may be considered in specific circumstances:
  • Stereotactic surgery for patients with deep ICH 2
  • Craniotomy for patients where hematoma is superficial (<1 cm from surface) 2
• Neurosurgical consultation should be obtained promptly for evaluation of potential surgical interventions 1

Prevention of Complications

• Oxygen supplementation should be provided to patients who are hypoxic 2
• Patients with hyperglycemia should have their blood glucose level monitored and appropriate glycemic therapy instituted 2
• 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

Pitfalls and Caveats

• Avoid self-fulfilling prophecy of poor outcome by limiting treatment due to presumed poor prognosis 3
• Diagnostic tests should not delay imaging or treatment decisions 1
• Physiologic predictors of mortality include blood pressure, serum pH, and PaO2 on admission 4
• Respiratory rate and hematocrit on admission are significant predictors of functional recovery 4