What are the management strategies for hemorrhagic stroke?

Management of Hemorrhagic Stroke

Immediate management of hemorrhagic stroke requires rapid assessment, stabilization, and specialized care in a stroke unit or neurocritical care setting to reduce mortality and improve outcomes. 1, 2

Initial Assessment and Stabilization

• Treat hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with expertise in hyperacute stroke management 1, 2
• Perform rapid assessment of airway, breathing, and circulation (ABCs) immediately upon arrival 1
• Conduct neurological examination to determine focal deficits and assess stroke severity using standardized scales such as the National Institutes of Health Stroke Scale (NIHSS) 2
• Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage 1, 2
• Order urgent blood work including complete blood count, coagulation status, and blood glucose 2
• Evaluate medication history, particularly focusing on anticoagulant or antiplatelet therapy 2
• Consider vascular imaging to exclude underlying lesions such as aneurysms or arteriovenous malformations 2

Blood Pressure Management

• Monitor blood pressure every 15 minutes until stabilized 1, 2
• For patients with systolic blood pressure between 150-220 mmHg, acute lowering to 140 mmHg is safe and can improve functional outcomes 1, 2
• Use small boluses of labetalol or nicardipine for hypertension management 1
• Avoid antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 3

Management of Coagulopathy

• Rapidly reverse anticoagulation while limiting fluid volumes 1
• 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 2

Fluid Management

• Use isotonic fluids to maintain hydration while preventing volume overload 1
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 3, 1
• Mild restriction of fluids is recommended to help manage brain edema 3

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to help venous drainage 3, 1
• Treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 3, 1
• Consider osmotherapy and hyperventilation for patients whose condition is deteriorating secondary to increased intracranial pressure 3
• Surgical interventions, including drainage of cerebrospinal fluid, can be used to treat increased intracranial pressure secondary to hydrocephalus 3

Seizure Management

• Treat new-onset seizures occurring within 24 hours of stroke onset with appropriate short-acting medications 1, 2
• Single, self-limiting seizures at onset or within 24 hours should not receive long-term anticonvulsant medications 2
• Recurrent seizures should be treated as with any other acute neurological condition 3
• Prophylactic administration of anticonvulsants to patients who have had stroke but not seizures is not recommended 3

Surgical Considerations

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 1, 2
• 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, 2
• Surgical decompression and evacuation of large cerebellar infarctions leading to brain stem compression and hydrocephalus is recommended 3
• Early surgery should be considered for patients with a Glasgow Coma Scale score 9–12 3

Prevention of Complications

• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 3, 2
• Consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 3
• Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 2

Monitoring and Care Setting

• Provide initial monitoring and management in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1, 2
• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1, 2
• Corticosteroids are not recommended for the management of cerebral edema and increased intracranial pressure following stroke 3

Important Pitfalls to Avoid

• Be vigilant for early deterioration, which is common in the first few hours after ICH onset (over 20% of patients experience a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation) 1, 2
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome 1, 2
• Avoid delaying imaging or treatment decisions while waiting for diagnostic test results 2
• Avoid permissive hypotension during resuscitation except in exceptional circumstances 1
• Do not use graduated compression stockings as they are less effective than intermittent pneumatic compression for VTE prevention 3