What is the management plan for acute hemorrhagic stroke?

Management of Acute Hemorrhagic Stroke

The management of acute hemorrhagic stroke requires immediate evaluation by physicians with expertise in hyperacute stroke management, with rapid assessment of airway, breathing, and circulation, followed by urgent neuroimaging, blood pressure control, and consideration of surgical intervention for selected patients. 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 using standardized scales such as the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and stroke severity 1
• Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage 1, 2
• Monitor neurological status (including Glasgow Coma Scale) and vital signs regularly, as early deterioration is common in the first few hours after intracerebral hemorrhage onset 2

Diagnostic Workup

• Perform urgent blood work including 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, obtain vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 1
• Be aware that laboratory test results should be available on-site within 20 minutes after blood sampling 2

Blood Pressure Management

• Assess blood pressure 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, acutely lower systolic BP to 140 mmHg as this is safe and can improve functional outcomes 1, 2
• Intensive blood pressure control (target systolic <140 mmHg) has been shown to reduce the risk of hematoma expansion and improve functional outcomes 3

Management of Coagulopathy

• For patients with severe coagulation factor deficiency or severe thrombocytopenia, provide appropriate factor replacement therapy or platelets 1
• For patients with elevated INR due to vitamin K antagonists, withhold medication, administer therapy to replace vitamin K-dependent factors, correct the INR, and give intravenous vitamin K 1

Seizure Management

• Treat new onset seizures occurring immediately before or within 24 hours of stroke onset with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited 1
• Do not treat a single, self-limiting seizure occurring at onset or within 24 hours with long-term anticonvulsant medications 1

Surgical Considerations

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 1
• For patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction, perform surgical removal of the hemorrhage as soon as possible 1, 2
• Consider surgical evacuation for cerebellar hemisphere hematomas >3 cm diameter in selected patients 2
• For supratentorial hemorrhage, routine surgery is not recommended but may be considered in specific circumstances, such as stereotactic surgery for patients with deep ICH or craniotomy for patients where hematoma is superficial (<1 cm from surface) 2

Prevention of Complications

• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1
• Perform formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1
• Provide oxygen supplementation to patients who are hypoxic 2
• Monitor and manage blood glucose levels in patients with hyperglycemia 2

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
• Conduct a validated neurological scale at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1

Pitfalls and Caveats

• Be aware that 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
• Recognize that 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, 2
• Do not delay imaging or treatment decisions while waiting for diagnostic test results 1
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 1
• Avoid self-fulfilling prophecy of poor outcome by limiting treatment due to presumed poor prognosis 4