What is the immediate management of hemorrhagic stroke?

Immediate Management of Hemorrhagic Stroke

Hemorrhagic stroke requires immediate emergency treatment with rapid blood pressure control, reversal of any coagulopathy, and neurosurgical consultation, while avoiding interventions that worsen cerebral edema or intracranial pressure. 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, 2
• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and stroke severity 1, 2
• Obtain immediate CT or MRI neuroimaging to confirm diagnosis, location, and extent of hemorrhage 1, 2
• Order urgent blood work including complete blood count, coagulation status (INR, aPTT), and blood glucose 1, 2
• Evaluate medication history with specific focus on anticoagulant or antiplatelet therapy 1, 2
• Consider vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 1, 2

Critical pitfall: Early deterioration is common in the first few hours after intracerebral hemorrhage (ICH) onset, with over 20% of patients experiencing significant decline between prehospital assessment and initial ED evaluation. 2

Blood Pressure Management

For patients with systolic blood pressure between 150-220 mmHg, acute lowering to 140 mmHg is safe and can improve functional outcomes. 1, 2

• Assess blood pressure on initial arrival and every 15 minutes until stabilized 1, 2
• Use small boluses of labetalol for hypertension management 1
• Nicardipine is superior to labetalol for achieving and maintaining goal blood pressure, with faster response time and fewer treatment failures 3, 4
• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 5, 2, 6
• After correcting hypovolemia or excess sedation, manage hypotension with small boluses of an α-agonist followed by an infusion 1

The evidence strongly supports nicardipine over labetalol: nicardipine achieves goal blood pressure in 100% of patients versus 61% with labetalol, with 89% reaching goal within 60 minutes versus only 25% with labetalol. 4 However, both agents are acceptable per guidelines. 5

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 should receive appropriate factor replacement therapy 1, 2
• Patients with severe thrombocytopenia should receive platelets 1, 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 worsen cerebral edema 1, 2
• Avoid Ringer's lactate, Ringer's acetate, and gelatins as they are hypotonic in terms of real osmolality 1
• Do not use albumin or other synthetic colloids in early management 1
• Mild restriction of fluids is recommended to help manage brain edema 2

Management of Increased Intracranial Pressure

Elevate the head of the bed by 20-30 degrees to help venous drainage. 1, 2

• Treat factors that exacerbate raised intracranial pressure: hypoxia, hypercarbia, and hyperthermia 1, 2
• Consider osmotherapy (mannitol 0.25-0.5 g/kg IV over 20 minutes, every 6 hours, maximum 2 g/kg) for patients whose condition is deteriorating due to increased intracranial pressure 5, 2
• Hyperventilation can be used as a temporizing measure for patients with herniation syndromes 5, 2
• Surgical interventions, including drainage of cerebrospinal fluid, can be used to treat increased intracranial pressure secondary to hydrocephalus 2
• Corticosteroids are not recommended for management of cerebral edema and increased intracranial pressure 5, 2

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 5, 2
• Prophylactic administration of anticonvulsants is not recommended 1, 2

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
• Consider surgical decompression and evacuation of large cerebellar infarctions leading to brain stem compression and hydrocephalus 2
• Early surgery should be considered for patients with a Glasgow Coma Scale score 9-12 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, 2

• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1, 2
• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1, 2
• Do not use graduated compression stockings as they are less effective than intermittent pneumatic compression 2
• Consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 2
• Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1, 2

Critical Pitfalls to Avoid

Hematoma expansion occurs in 30-40% of patients and is a predictor of poor outcome. 1, 2

• Risk factors for expansion include presence of contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume 2
• 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 1
• Avoid permissive hypotension during resuscitation except in exceptional circumstances 1
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 2