From the Guidelines
The treatment plan for hemorrhagic stroke should prioritize stopping the bleeding, reducing pressure in the brain, and preventing complications, with a focus on emergency care, blood pressure control, and supportive care, as outlined in the most recent guidelines from the American Heart Association and other reputable sources 1. The goal of treatment is to minimize morbidity, mortality, and improve quality of life, with a comprehensive approach that addresses the immediate crisis and works to prevent recurrence.
Key Components of Treatment
- Emergency care with blood pressure control using medications like nicardipine, labetalol, or clevidipine to maintain systolic pressure between 140-160 mmHg
- Discontinuation of any anticoagulant or antiplatelet medications and reversal of coagulopathy with protamine sulfate for heparin, vitamin K and prothrombin complex concentrate for warfarin, or specific reversal agents for newer anticoagulants
- Surgical interventions, such as external ventricular drainage, surgical evacuation of large hematomas, or endovascular procedures for aneurysms
- Supportive care, including maintaining adequate oxygenation, preventing seizures with medications like levetiracetam (500-1000 mg twice daily), controlling fever, managing blood glucose levels, and preventing deep vein thrombosis with pneumatic compression devices
Rehabilitation and Secondary Prevention
Once stabilized, rehabilitation should begin as soon as possible, including physical, occupational, and speech therapy, with a focus on minimizing long-term disability and improving quality of life. Secondary prevention includes blood pressure management with a target below 130/80 mmHg, lifestyle modifications, and treatment of underlying causes such as aneurysms or arteriovenous malformations, as recommended by the Canadian Stroke Best Practice Recommendations 1.
Evidence-Based Recommendations
The treatment plan should be guided by the most recent and highest quality evidence, with a focus on minimizing morbidity, mortality, and improving quality of life, as outlined in the guidelines from the American Heart Association and other reputable sources 1.
From the Research
Treatment Plan for Hemorrhagic Stroke
The treatment plan for a hemorrhagic stroke involves several key components, including:
- Airway management and management of blood pressure aimed at maximizing cerebral perfusion while minimizing ongoing bleeding 2
- Rapid reversal of anticoagulation 2, 3
- Careful glucose management and temperature management to maximize cerebral perfusion pressure 2
- Efforts to provide supportive care, such as thromboembolism prophylaxis, physical therapy, and acute rehabilitation 2
- Selected patients may benefit from external ventricular drainage or even hematoma evacuation 2
Management in the Emergency Department
In the emergency department, treatment focuses on:
- Correction of abnormal coagulopathies 3
- Blood pressure reduction 3, 4
- Emergent treatment of intracranial hypertension 3
- Recognition of those in need of urgent surgical decompression 3
Critical Care Management
Patients with hemorrhagic stroke should be managed in a neuroscience intensive care unit during the acute phase, with expertise in neurocritical care if available 2, 3. Critical care management involves: