What is the management approach for acute hemorrhagic stroke?

Acute Hemorrhagic Stroke Management

Immediate Stabilization and Assessment

Treat acute 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 performed immediately upon arrival. 1, 2

• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) for awake or drowsy patients to determine focal deficits and stroke severity 1
• Monitor Glasgow Coma Scale, vital signs (pulse, blood pressure, temperature, oxygen saturation), and glucose regularly during the acute phase 2
• Recognize that early deterioration is common—over 20% of patients experience a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation 1, 2
• Admit patients to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1

Diagnostic Workup

Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage—this is mandatory and should not be delayed. 1, 2

• Perform urgent blood work including complete blood count, coagulation status (INR, aPTT), and blood glucose 1, 2
• Ensure laboratory results are available within 20 minutes of blood sampling 2
• Obtain detailed medication history with particular attention to anticoagulant therapy 1, 2
• Perform vascular imaging (CT angiography, MR angiography, or catheter angiography) in confirmed ICH to exclude underlying lesions such as aneurysms or arteriovenous malformations 1, 2
• Recognize that hematoma expansion 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, 2

Blood Pressure Management

For ICH patients with systolic blood pressure between 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg—this is safe and can improve functional outcomes. 1, 2

• Assess blood pressure on initial arrival and every 15 minutes until stabilized 1, 2
• In ICH patients with a history of hypertension, maintain mean arterial pressure below 130 mmHg 2
• Use nicardipine rather than labetalol for achieving and maintaining goal blood pressure, as it has faster response time and fewer treatment failures 1
• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 1

Coagulopathy Reversal

Patients with elevated INR due to vitamin K antagonists must have their medication withheld immediately, receive therapy to replace vitamin K-dependent factors, correct the INR, and receive intravenous vitamin K. 1, 2

• Administer appropriate factor replacement therapy or platelets to patients with severe coagulation factor deficiency or severe thrombocytopenia 1, 2

Management of Increased Intracranial Pressure

Elevate the head of the bed by 20-30 degrees to help venous drainage in all patients. 1

• Treat factors that exacerbate raised intracranial pressure including hypoxia, hypercarbia, and hyperthermia 1
• Consider osmotherapy with mannitol 0.25-0.5 g/kg IV over 20 minutes, every 6 hours (maximum 2 g/kg) for patients deteriorating due to increased intracranial pressure 1
• Use hyperventilation as a temporizing measure for patients with herniation syndromes 1
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they worsen cerebral edema 1
• Use mild fluid restriction to help manage brain edema 1
• Do NOT use corticosteroids for management of cerebral edema and increased intracranial pressure—they are not recommended 3, 1
• Consider drainage of cerebrospinal fluid for increased intracranial pressure secondary to hydrocephalus 1

Surgical Considerations

Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction must undergo surgical removal of the hemorrhage as soon as possible. 1, 2

• Obtain neurosurgical consultation promptly for evaluation of potential surgical interventions 1
• Consider surgical evacuation for cerebellar hemisphere hematomas >3 cm diameter in selected patients 2
• Consider early surgery for supratentorial ICH patients with Glasgow Coma Scale score 9-12 3, 1
• For supratentorial hemorrhage, routine surgery is not recommended, but consider stereotactic surgery for deep ICH or craniotomy when hematoma is superficial (<1 cm from surface) 2

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. 3, 1

• Do NOT treat a single, self-limiting seizure occurring at onset or within 24 hours with long-term anticonvulsant medications 1
• Treat recurrent seizures as with any other acute neurological condition 1
• Do NOT use prophylactic anticonvulsants in patients who have had stroke but not seizures 1

Prevention of Complications

Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission. 3, 1

• Apply intermittent pneumatic compression devices as soon as possible and within the first 24 hours after admission 3
• Do NOT use graduated compression stockings alone—they are less effective than intermittent pneumatic compression 3, 1
• Consider starting pharmacological VTE prophylaxis with unfractionated heparin or low-molecular-weight heparin after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 1
• Perform a formal screening procedure for dysphagia before initiating oral intake to reduce the risk of pneumonia 1
• Provide oxygen supplementation to patients who are hypoxic 2
• Monitor blood glucose in patients with hyperglycemia and institute appropriate glycemic therapy 2

Monitoring Protocol

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

• Monitor temperature as part of vital sign assessments ideally every 4 hours for the first 48 hours 3
• For temperature >37.5°C, increase monitoring frequency, initiate temperature-reducing measures, investigate possible infection (pneumonia or urinary tract infection), and initiate antipyretic and antimicrobial therapy as required 3

Common Pitfalls

• Hematoma expansion is a major predictor of poor outcome and occurs in 30-40% of patients—early aggressive management is critical 1, 2
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 1
• Do not delay imaging or treatment decisions for diagnostic tests 1
• Avoid self-fulfilling prophecy of poor outcome by limiting treatment due to presumed poor prognosis 4