From the Guidelines
Post-treatment care for a patient who had a hemorrhagic stroke should focus on preventing complications, managing symptoms, and promoting recovery, with a primary goal of maintaining systolic blood pressure below 140 mmHg using medications like labetalol or nicardipine, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Key Considerations
- Blood pressure control is crucial in the acute phase, with a target systolic pressure of 140-160 mmHg to prevent hematoma expansion and improve functional outcome 1.
- Seizure prophylaxis may be considered with levetiracetam for 7 days in patients with lobar hemorrhages.
- Deep vein thrombosis prophylaxis should begin 24-48 hours after bleeding stabilizes, using intermittent pneumatic compression initially, followed by low molecular weight heparin like enoxaparin.
- Rehabilitation should start as soon as the patient is medically stable, including physical, occupational, and speech therapy.
- Patients should avoid anticoagulants and antiplatelet agents initially, with careful consideration of restarting these medications after 4-8 weeks if indicated for other conditions.
Long-term Management
- Blood pressure should be maintained long-term at <130/80 mmHg with appropriate antihypertensives.
- Lifestyle modifications are essential, including smoking cessation, limited alcohol intake, regular exercise, and a low-sodium diet.
- Regular follow-up imaging may be necessary to monitor hematoma resolution and to evaluate for underlying vascular abnormalities that might require specific treatment.
Additional Recommendations
- Cardiac monitoring is recommended to screen for atrial fibrillation and other potentially serious cardiac arrhythmias for at least the first 24 h 1.
- Gradual early mobilization should be encouraged, and patients who have limited mobility should be treated with thigh-high intermittent pneumatic compression devices (IPC) 1.
- Body temperature should be monitored, and fever should be treated, with sources of fever investigated and treated 1.
From the Research
Post-Treatment Considerations for Hemorrhagic Stroke
- Blood pressure management is a crucial aspect of post-treatment care for patients who have experienced a hemorrhagic stroke 2, 3, 4.
- The optimal blood pressure target for these patients is still a topic of debate, but most studies suggest that a systolic blood pressure (SBP) of less than 140 mmHg may be beneficial in reducing hematoma growth 4.
- However, intensive blood pressure lowering (SBP < 140 mmHg) has not been shown to significantly improve functional outcomes compared to guideline-based blood pressure lowering (SBP < 180 mmHg) 4.
- The choice of antihypertensive agent may also play a role in post-treatment care, with nicardipine potentially being more effective than labetalol in achieving and maintaining goal blood pressure 5.
Medication Management
- Patients who were taking non-vitamin K antagonist oral anticoagulants (NOACs) prior to their stroke may require special consideration in terms of medication management 6.
- The ARAMIS Registry is a multicenter cohort study that aims to provide a comprehensive picture of current treatment patterns and outcomes for acute stroke patients on NOACs, as well as anticoagulation-related intracerebral hemorrhage in patients on either warfarin or NOACs 6.
Ongoing Care
- Ongoing care for patients who have experienced a hemorrhagic stroke may involve close monitoring of blood pressure, as well as management of any underlying conditions that may have contributed to the stroke 2, 3.
- Further research is needed to clarify the specific scope and time of blood pressure reduction in these patients, as well as the optimal strategies for caring for patients on NOACs who experience an acute ischemic stroke or intracerebral hemorrhage 4, 6.