What is the initial management of a patient presenting with hemorrhagic stroke?

Initial Management of Hemorrhagic Stroke

Treat hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with expertise in hyperacute stroke management, with priority equal to acute myocardial infarction. 1, 2

Immediate Assessment and Stabilization (First 15 Minutes)

Perform rapid ABC assessment immediately upon arrival, focusing on airway protection in patients with depressed consciousness (GCS <8 typically requires intubation). 1, 2

• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify deficit severity and establish baseline. 1, 2
• Determine exact time of symptom onset—this is critical for all subsequent management decisions. 3
• Obtain immediate non-contrast CT scan to confirm diagnosis, location, and extent of hemorrhage—do not delay imaging for any diagnostic tests. 1, 2

Blood Pressure Management (Critical First Hour)

For patients with systolic BP 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg—this is safe and improves functional outcomes. 1, 2

• Monitor BP every 15 minutes until stabilized. 1, 2
• Use nicardipine as first-line agent—it is superior to labetalol for achieving and maintaining goal BP with faster response time and fewer treatment failures. 1
• Avoid sodium nitroprusside in patients with elevated intracranial pressure as it causes cerebral vasodilation. 1
• Use small boluses of labetalol as alternative if nicardipine unavailable. 2

Urgent Diagnostic Workup (Within 30 Minutes)

Order complete blood count, coagulation studies (INR, aPTT), and blood glucose immediately. 1, 2

• Obtain detailed medication history focusing specifically on anticoagulants and antiplatelet agents. 1, 2
• Perform vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations—this is mandatory in confirmed acute ICH. 1

Reversal of Coagulopathy (Immediate Priority)

For patients on warfarin with elevated INR: administer prothrombin complex concentrate plus intravenous vitamin K immediately. 1, 2

• Withhold all anticoagulant medications. 1
• For severe thrombocytopenia, transfuse platelets to achieve adequate hemostasis. 1, 2
• Rapidly reverse anticoagulation while limiting fluid volumes to prevent volume overload. 2

Fluid Management

Use only isotonic fluids to maintain hydration—avoid all hypo-osmolar solutions. 2

• Never use 5% dextrose in water, Ringer's lactate, Ringer's acetate, or gelatins as they worsen cerebral edema. 1, 2
• Do not use albumin or synthetic colloids in early management. 2
• Implement mild fluid restriction to help manage brain edema. 1

Management of Increased Intracranial Pressure

Elevate head of bed 20-30 degrees to facilitate venous drainage. 1, 2

• Treat all factors exacerbating raised ICP: hypoxia, hypercarbia, and hyperthermia. 1, 2
• For patients deteriorating from increased ICP, administer mannitol 0.25-0.5 g/kg IV over 20 minutes, every 6 hours (maximum 2 g/kg). 1
• Use hyperventilation only as temporizing measure for herniation syndromes. 1
• Do not use corticosteroids—they are not recommended for cerebral edema management in hemorrhagic stroke. 1, 2

Seizure Management

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

• Do not treat single, self-limiting seizures with long-term anticonvulsants. 1, 2
• Treat recurrent seizures with standard acute seizure protocols. 1, 2
• Do not use prophylactic anticonvulsants in patients without seizures. 1, 2

Surgical Evaluation (Immediate Consultation)

Obtain prompt neurosurgical consultation for all hemorrhagic stroke patients. 1, 2

• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus require surgical removal as soon as possible. 1, 2
• Consider early surgery for patients with Glasgow Coma Scale score 9-12. 1
• Surgical drainage of CSF can treat increased ICP secondary to hydrocephalus. 1

Monitoring and Care Setting

Admit all patients to intensive care unit or dedicated stroke unit with neuroscience acute care expertise. 1, 2

• Perform validated neurological scale assessments at baseline and repeat at least hourly for first 24 hours. 1, 2
• Implement cardiac monitoring for at least 24 hours to screen for arrhythmias. 3

Prevention of Acute Complications

Apply intermittent pneumatic compression devices immediately on day of admission for VTE prophylaxis. 1, 2

• Perform formal dysphagia screening using validated tool before any oral intake to reduce pneumonia risk. 1, 2
• Keep patient NPO until swallowing safety confirmed. 3
• Consider pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset. 1
• Do not use graduated compression stockings—they are less effective than intermittent pneumatic compression. 1

Critical Pitfalls to Avoid

Be vigilant for early deterioration—over 20% of patients experience decrease in GCS of 2+ points between prehospital assessment and initial ED evaluation. 1

• Monitor for hematoma expansion, which occurs in 30-40% of patients and predicts poor outcome—risk factors include contrast extravasation ("spot sign"), early presentation (<3 hours), anticoagulant use, and large initial hematoma volume. 1
• Never delay imaging or treatment decisions while waiting for diagnostic test results. 1, 2
• Do not transfer hypotensive, actively bleeding patients—control hemorrhage before transfer. 2