What are the management strategies and medication doses for acute hemorrhagic stroke?

Management of Acute Hemorrhagic Stroke

Immediate Stabilization and Assessment

All patients with acute hemorrhagic stroke must be treated as a medical emergency with immediate evaluation by physicians with expertise in hyperacute stroke management. 1, 2

Initial Actions (First 15 Minutes)

• Assess airway, breathing, and circulation (ABCs) immediately upon arrival - intubate patients with decreased consciousness or bulbar dysfunction 1, 3
• Obtain immediate non-contrast CT scan to confirm diagnosis, location, and extent of hemorrhage - this is mandatory and should not be delayed 1, 2
• Perform neurological examination using NIHSS for awake/drowsy patients and Glasgow Coma Scale (GCS) for all patients 1, 2
• Check blood pressure every 15 minutes until stabilized 1, 2
• Draw urgent labs: complete blood count, INR, aPTT, platelet count, and blood glucose 1, 2

Critical Early Warning

Over 20% of patients deteriorate significantly (GCS drop ≥2 points) between prehospital assessment and ED arrival, and 30-40% experience hematoma expansion in the first hours - this is the highest risk period 1, 2

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Blood Pressure Management

Target Blood Pressure

For patients with systolic BP 150-220 mmHg and no contraindications, acutely lower systolic BP to <140 mmHg within 6 hours - this is safe and improves functional outcomes 4, 1, 2

• For patients with history of hypertension, maintain mean arterial pressure <130 mmHg 2
• Reassess BP every 15 minutes until target achieved and stable 1, 2

Medication Selection

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

• Nicardipine: 5 mg/hour IV infusion, titrate by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour 1
• Avoid sodium nitroprusside in patients with elevated intracranial pressure as it causes cerebral vasodilation 1

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Coagulopathy Reversal

Warfarin-Associated ICH

Immediately withhold warfarin and aggressively reverse anticoagulation 1, 2

• Administer prothrombin complex concentrate (PCC) or fresh frozen plasma to replace vitamin K-dependent factors 1
• Give intravenous vitamin K 10 mg 1
• Goal: correct INR urgently 1

Thrombocytopenia and Coagulation Factor Deficiency

• Transfuse platelets for severe thrombocytopenia 1, 2
• Replace coagulation factors for severe deficiency 1, 2

Hemostatic Agents

Do NOT use recombinant Factor VIIa (rFVIIa) outside clinical trials - it is considered experimental and not recommended for routine use 4

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Monitoring and Care Setting

Location and Frequency

Admit to intensive care unit or dedicated stroke unit with neuroscience expertise 1

• Perform neurological assessment using validated scale at baseline, then hourly for first 24 hours 1
• Monitor vital signs continuously: pulse, BP, temperature, oxygen saturation, glucose 2

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Management of Increased Intracranial Pressure

Positioning and Basic Measures

• Elevate head of bed 20-30 degrees to improve venous drainage 1
• Treat exacerbating factors: hypoxia, hypercarbia, hyperthermia 1

Osmotherapy

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

• Hyperventilation can be used as temporizing measure for herniation syndromes 1
• Do NOT use corticosteroids - they are not recommended for cerebral edema management 4, 1

Hydrocephalus Management

• Surgical drainage of cerebrospinal fluid for increased ICP secondary to hydrocephalus 1

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Surgical Interventions

Cerebellar Hemorrhage (Urgent Indication)

Patients with cerebellar hemorrhage >3 cm diameter who are deteriorating neurologically or have brainstem compression and/or hydrocephalus require immediate surgical evacuation 4, 1, 2

• Obtain neurosurgical consultation immediately upon diagnosis 1

Supratentorial Hemorrhage

Routine surgical evacuation is NOT recommended for supratentorial ICH 4, 2

• Consider craniotomy for superficial ICH <1 cm from cortical surface in selected patients 4, 2
• Consider stereotactic surgery for deep ICH in selected patients 4, 2

Decompressive Hemicraniectomy

For ischemic stroke with malignant MCA infarction in patients 18-60 years old, perform hemicraniectomy within 48 hours if significant swelling develops 4

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Seizure Management

Acute Seizures

For new-onset seizures occurring at stroke onset or within 24 hours, treat with lorazepam IV if not self-limited 1

• Lorazepam: 2-4 mg IV, may repeat once 1
• Do NOT start prophylactic anticonvulsants for single self-limited seizure 1

Recurrent Seizures

• Treat recurrent seizures as with any acute neurological condition 1
• Do NOT use prophylactic anticonvulsants in patients without seizures 1

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Prevention of Complications

Venous Thromboembolism Prophylaxis

Begin intermittent pneumatic compression (IPC) on day of admission 4, 1, 2

• Consider adding pharmacological prophylaxis with unfractionated heparin or LMWH after 24-48 hours once hemorrhage stability documented on repeat CT 1
• Do NOT use graduated compression stockings - they are less effective than IPC 4, 1

Aspiration Prevention

• Perform formal dysphagia screening before any oral intake to reduce pneumonia risk 1

Metabolic Management

• Provide supplemental oxygen to maintain saturation >94% 3
• Treat hypoglycemia (glucose <60 mg/dL) immediately 3
• Treat hyperglycemia with goal blood glucose 140-180 mg/dL 3
• Identify and treat sources of fever (temperature >38°C) 3

Fluid Management

• Avoid hypo-osmolar fluids (5% dextrose in water) as they worsen cerebral edema 1
• Use normal saline for volume resuscitation 3
• Mild fluid restriction may help manage brain edema 1

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Diagnostic Workup

Vascular Imaging

Perform CT angiography, MR angiography, or catheter angiography to exclude underlying vascular lesions (aneurysms, arteriovenous malformations) in all confirmed ICH patients 1, 2

Laboratory Timing

• Laboratory results must be available within 20 minutes of blood sampling 2
• Do NOT delay imaging or treatment decisions for diagnostic tests 1

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Critical Pitfalls to Avoid

• Do NOT delay CT imaging - it is the single most important initial test 1, 2
• Do NOT use aspirin or other antiplatelet agents acutely - these are contraindicated in hemorrhagic stroke 4
• Do NOT start anticoagulation - this worsens outcomes 4
• Do NOT assume poor prognosis limits treatment - avoid self-fulfilling prophecy by withholding appropriate care based on prognostic scores alone 5
• Do NOT use antihypertensive agents that cause cerebral vasodilation (sodium nitroprusside) in patients with elevated ICP 1