What are the management strategies for hemorrhagic stroke?

Management of Hemorrhagic Stroke

Immediate Stabilization and Assessment

Treat hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with expertise in hyperacute stroke management, with rapid assessment of airway, breathing, and circulation (ABCs) performed immediately upon arrival. 1, 2

• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to assess stroke severity and focal deficits 1, 2
• Obtain immediate non-contrast head CT scan to confirm diagnosis, location, and extent of hemorrhage—this is the mandatory first imaging study 1, 2
• Order urgent blood work including complete blood count, coagulation status (INR, aPTT), and blood glucose 1, 2
• Specifically evaluate for anticoagulant or antiplatelet medication use in the history 1, 2
• Perform vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 1

Blood Pressure Management

For patients with systolic blood pressure between 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg within six hours of ICH onset—this is safe and can improve functional outcomes. 3, 1

• Monitor blood pressure every 15 minutes until stabilized 1, 2
• Use small boluses of labetalol for hypertension management 2
• Avoid antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 1, 2
• For hypotension after correcting hypovolemia or excess sedation, use small boluses of an α-agonist followed by an infusion 2

Reversal of Coagulopathy

Patients on warfarin with elevated INR must receive prothrombin complex concentrate plus intravenous vitamin K immediately to reverse anticoagulation. 2

• Withhold vitamin K antagonists and administer therapy to replace vitamin K-dependent factors 1
• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1, 2
• Rapidly reverse anticoagulation while limiting fluid volumes 2

Monitoring and Care Setting

Initial monitoring and management must take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise. 3, 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
• Be vigilant for early deterioration—over 20% of patients experience a decrease in Glasgow Coma Scale of 2 or more points between prehospital assessment and initial ED evaluation 1
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome; risk factors include contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume 1

Fluid Management

Use isotonic fluids to maintain hydration while preventing volume overload—avoid hypo-osmolar fluids such as 5% dextrose in water as they worsen cerebral edema. 1, 2

• Do not use Ringer's lactate, Ringer's acetate, or gelatins as they are hypotonic in terms of real osmolality 2
• Do not use albumin or other synthetic colloids in early management 2
• Implement mild restriction of fluids to help manage brain edema 1

Management of Increased Intracranial Pressure

Elevate the head of the bed by 20-30 degrees to help venous drainage and treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia). 1, 2

• Consider osmotherapy and hyperventilation for patients whose condition is deteriorating secondary to increased intracranial pressure 1
• Surgical drainage of cerebrospinal fluid can be used to treat increased intracranial pressure secondary to hydrocephalus 1
• Do not use corticosteroids for the management of cerebral edema and increased intracranial pressure following stroke 3, 1

Seizure Management

Treat new-onset seizures occurring within 24 hours of stroke onset with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited. 1, 2

• A single, self-limiting seizure at onset or within 24 hours should not receive long-term anticonvulsant medications 1, 2
• Recurrent seizures should be treated as with any other acute neurological condition 1, 2
• Do not use prophylactic anticonvulsants in patients who have not had seizures 1, 2

Surgical Considerations

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

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

Prevention of Complications

Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission—do not use graduated compression stockings as they are less effective. 3, 1, 2

• Consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 1
• Perform formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1, 2

Critical Pitfalls to Avoid

• Do not delay imaging or treatment decisions while waiting for diagnostic test results 1, 2
• Do not transfer patients who are hypotensive and actively bleeding; control hemorrhage before transfer 2
• Avoid hemostatic therapy for acute ICH not associated with antithrombotic drug use—this has no proven benefit 3
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 1