What is the medical management of hemorrhagic stroke?

Medical Management of Hemorrhagic Stroke

The medical management of hemorrhagic stroke requires immediate treatment in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise to optimize outcomes and reduce mortality. 1

Initial Assessment and Stabilization

• Treat hemorrhagic stroke as a medical emergency with immediate evaluation by physicians with expertise in hyperacute stroke management 2
• Perform rapid assessment of airway, breathing, and circulation (ABCs) immediately upon arrival 2
• Conduct neurological examination using standardized scales such as the National Institutes of Health Stroke Scale (NIHSS) or Glasgow Coma Scale (GCS) 1, 2
• Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage 1, 2
• Complete urgent blood work including complete blood count, coagulation status (INR, aPTT), and blood glucose 1, 3
• Evaluate medication history, particularly focusing on anticoagulant or antiplatelet therapy 1, 3

Blood Pressure Management

• Monitor blood pressure every 15 minutes until stabilized 3
• For patients with systolic blood pressure between 150-220 mmHg, acute lowering to 140 mmHg is safe and can improve functional outcomes 2, 3
• Begin blood pressure control measures immediately after ICH onset 1
• Avoid rapid or excessive lowering of blood pressure as this might exacerbate existing ischemia 1
• Avoid antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 2

Management of Coagulopathy

• Rapidly reverse anticoagulation while limiting fluid volumes 3
• For patients on warfarin with elevated INR, administer prothrombin complex concentrate plus intravenous vitamin K 3
• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 2, 3

Fluid Management

• Use isotonic fluids to maintain hydration while preventing volume overload 3
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 2, 3
• Avoid Ringer's lactate, Ringer's acetate, and gelatins as they are hypotonic in terms of real osmolality 3

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to help venous drainage 2, 3
• Treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 2, 3
• Consider osmotherapy for patients whose condition is deteriorating due to increased intracranial pressure 2
• Recent evidence suggests maintaining ICP below 16.5 mmHg may improve 28-day ICU mortality 4

Seizure Management

• Treat clinical seizures with appropriate antiseizure drugs 1
• Patients with a change in mental status who have electrographic seizures on EEG should be treated with antiseizure drugs 1
• Single, self-limiting seizures at onset or within 24 hours should not receive long-term anticonvulsant medications 2, 3
• Prophylactic administration of anticonvulsants is not recommended 3

Glucose Management

• Monitor glucose levels regularly 1
• Both hyperglycemia and hypoglycemia should be avoided as they can worsen outcomes 1

Surgical Considerations

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 2, 3
• 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, 3

Prevention of Complications

• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 2, 3
• Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1, 2
• Consider starting pharmacological VTE prophylaxis after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 2

Monitoring and Care

• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 2, 3
• Maintain normothermia through early application of measures to reduce heat loss 5
• Maintain arterial partial pressure of oxygen (PaO₂) between 60-100 mmHg 5
• Maintain arterial partial pressure of carbon dioxide (PaCO₂) between 35-40 mmHg to prevent cerebral vasoconstriction and risk of brain ischemia 5

Important Pitfalls to Avoid

• Be vigilant for early deterioration, which is common in the first few hours after ICH onset 2, 3
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome 2
• Avoid delaying imaging or treatment decisions while waiting for diagnostic test results 2, 3
• Avoid early pessimistic prognostication that may lead to self-fulfilling prophecies of poor outcome by limiting aggressive care 5
• Do not transfer patients who are hypotensive and actively bleeding; control hemorrhage before transfer 3

Rehabilitation

• All patients with ICH should have access to multidisciplinary rehabilitation given the potentially serious nature and complex pattern of evolving disability 1