What is the management of acute hemorrhagic stroke?

Management of Acute Hemorrhagic Stroke

Immediate Recognition and Stabilization

Acute intracerebral hemorrhage (ICH) must be treated as a medical emergency with immediate evaluation by physicians with expertise in hyperacute stroke management. 1, 2, 3

• Perform rapid assessment of airway, breathing, and circulation (ABCs) immediately upon arrival 2, 3
• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) for awake or drowsy patients, or Glasgow Coma Scale (GCS) for obtunded or comatose patients 1, 2, 3
• Monitor neurological status and vital signs (pulse, blood pressure, temperature, oxygen saturation, glucose) regularly during the acute phase 3
• Be aware 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 2, 3

Diagnostic Workup

Obtain immediate CT or MRI to confirm diagnosis, location, and extent of hemorrhage—this is mandatory and should not be delayed. 1, 2, 3

• Urgent blood work must include complete blood count, coagulation status (INR, aPTT), platelet count, and blood glucose 1, 2, 3
• Laboratory results should be available within 20 minutes of blood sampling 3
• Obtain detailed medication history with particular attention to anticoagulant and antiplatelet therapy 1, 2, 3
• Perform vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 1, 2, 3

Blood Pressure Management

For ICH patients presenting 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. 2, 3

• Assess blood pressure on initial arrival and every 15 minutes until stabilized 1, 2, 3
• Blood pressure targets may be challenging to achieve and require careful monitoring with aggressive repeated dosing or intravenous infusion of antihypertensive medications 1, 2
• In ICH patients with a history of hypertension, maintain mean arterial pressure below 130 mmHg 3
• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 2
• Nicardipine is superior to labetalol for achieving and maintaining goal blood pressure, with faster response time and fewer treatment failures 2

Reversal of Coagulopathy

Patients with elevated INR due to vitamin K antagonists should have their medication withheld immediately, receive therapy to replace vitamin K-dependent factors and correct the INR, and receive intravenous vitamin K. 2, 3

• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 2, 3
• Hematoma expansion occurs in 30-40% of patients and is a predictor of poor outcome; risk factors include presence of contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume 1, 2, 3

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to help venous drainage 2
• Treat factors that exacerbate raised intracranial pressure including hypoxia, hypercarbia, and hyperthermia 2, 3
• Consider osmotherapy with 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 2
• Hyperventilation can be used as a temporizing measure for patients with herniation syndromes 2
• Surgical interventions, including drainage of cerebrospinal fluid, can be used to treat increased intracranial pressure secondary to hydrocephalus 2
• Do not use corticosteroids for management of cerebral edema and increased intracranial pressure following ICH—they are not recommended. 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. 2, 3

• Surgical evacuation may be undertaken for cerebellar hemisphere hematomas >3 cm diameter in selected patients 3
• For supratentorial hemorrhage, routine surgery is not recommended but may be considered in specific circumstances, such as stereotactic surgery for patients with deep ICH or craniotomy for patients where hematoma is superficial (<1 cm from surface) 3
• Early surgery should be considered for patients with a Glasgow Coma Scale score 9-12 1, 2
• Obtain neurosurgical consultation promptly for evaluation of potential surgical interventions 2

Seizure Management

New onset seizures occurring immediately before or within 24 hours of stroke onset should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited. 2

• A single, self-limiting seizure occurring at onset or within 24 hours should not be treated with long-term anticonvulsant medications 2
• Recurrent seizures should be treated as with any other acute neurological condition 2
• Prophylactic administration of anticonvulsants to patients who have had stroke but not seizures is not recommended 2

Prevention of Complications

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 for VTE prevention 1, 2
• 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 2
• Perform a formal screening procedure for dysphagia before initiating oral intake to reduce the risk of pneumonia 2
• Provide oxygen supplementation to patients who are hypoxic 3
• Monitor and treat hyperglycemia with appropriate glycemic therapy 3
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 2

Monitoring and Care Setting

Initial monitoring and management should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise. 1, 2

• Conduct a validated neurological scale at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1, 2

Critical Pitfalls to Avoid

• Do not delay imaging or treatment decisions for diagnostic tests 2
• Do not use antihypertensive agents that cause cerebral vasodilation in patients with elevated intracranial pressure 2
• Do not use corticosteroids for cerebral edema management 1, 2
• Do not use graduated compression stockings for VTE prophylaxis 1, 2
• Do not start long-term anticonvulsants for a single self-limited seizure 2

1, 2, 3