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

Management of Hemorrhagic Stroke

Emergency Assessment and Initial Stabilization

Hemorrhagic stroke must be treated as a medical emergency with immediate evaluation by physicians with expertise in hyperacute stroke management, as early deterioration occurs in over 20% of patients within the first few hours. 1, 2

Immediate Actions Upon Arrival

• Perform rapid ABC assessment (airway, breathing, circulation) immediately upon patient arrival 2, 3
• 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, 2
• Obtain immediate non-contrast CT scan to confirm diagnosis, location, and extent of hemorrhage—this is mandatory and should not be delayed 2, 3
• Order urgent laboratory work including complete blood count, coagulation status (INR, aPTT), and random glucose 2, 3
• Obtain detailed medication history with specific focus on anticoagulant and antiplatelet therapy 2, 3

Advanced Imaging

• Perform vascular imaging (CT angiography, MR angiography, or catheter angiography) in confirmed acute ICH to exclude underlying lesions such as aneurysms or arteriovenous malformations 2
• Look for the "spot sign" on CT angiography, which indicates contrast extravasation and predicts hematoma expansion in 30-40% of patients—a major predictor of poor outcome 2

Blood Pressure Management

For patients with systolic blood pressure between 150-220 mmHg without contraindications, acute lowering of systolic BP to 140 mmHg is safe and can improve functional outcomes. 2, 3

BP Monitoring Protocol

• Assess blood pressure every 15 minutes until stabilized 2, 3
• Use small boluses of labetalol for hypertension management 3
• Avoid sodium nitroprusside and other antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 2
• For hypotension, after correcting hypovolemia or excess sedation, manage with small boluses of an α-agonist followed by an infusion 3

Special Considerations

• 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 on warfarin with elevated INR should receive prothrombin complex concentrate plus intravenous vitamin K immediately—rapid reversal while limiting fluid volumes is critical. 2, 3

Specific Reversal Strategies

• For vitamin K antagonists: Withhold medication, administer prothrombin complex concentrate, correct INR, and give intravenous vitamin K 2
• For severe coagulation factor deficiency: Provide appropriate factor replacement therapy 2, 3
• For severe thrombocytopenia: Administer platelets 2, 3

Fluid Management

Use isotonic fluids to maintain hydration while preventing volume overload—avoid hypo-osmolar fluids such as 5% dextrose in water as they worsen cerebral edema. 2, 3

Specific Fluid Restrictions

• Avoid Ringer's lactate, Ringer's acetate, and gelatins as they are hypotonic in terms of real osmolality 3
• Do not use albumin or other synthetic colloids in early management 3
• Implement mild fluid restriction to help manage brain edema 2

Management of Increased Intracranial Pressure

Elevate the head of the bed by 20-30 degrees to facilitate venous drainage and treat all factors that exacerbate raised intracranial pressure. 2, 3

ICP Management Protocol

• Treat hypoxia, hypercarbia, and hyperthermia aggressively as these exacerbate raised intracranial pressure 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 deteriorating due to increased intracranial pressure 2
• Use hyperventilation as a temporizing measure only for patients with herniation syndromes 2
• Do not use corticosteroids for management of cerebral edema and increased intracranial pressure following stroke 2
• Surgical drainage of cerebrospinal fluid can be used to treat increased intracranial pressure secondary to hydrocephalus 2

Seizure Management

New-onset seizures occurring within 24 hours of stroke onset should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited, but single self-limiting seizures should not receive long-term anticonvulsant therapy. 2, 3

Seizure Treatment Protocol

• Treat recurrent seizures as with any other acute neurological condition 2, 3
• Do not use prophylactic anticonvulsants in patients who have not had seizures 2, 3

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 Indications

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 2, 3
• Consider early surgery for patients with Glasgow Coma Scale score 9-12 2
• Perform ventriculostomy for patients with spontaneous ICH (with or without IVH) and symptomatic hydrocephalus 1
• Surgical decompression and evacuation is recommended for large cerebellar infarctions leading to brainstem compression and hydrocephalus 2

Monitoring and Care Setting

Initial monitoring and management must take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise. 2, 3

Monitoring Protocol

• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 2, 3
• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable 1
• Implement continuous cardiac telemetry for at least the first 24 hours to screen for atrial fibrillation and other potentially serious cardiac arrhythmias 1

Prevention of Complications

Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission—do not use graduated compression stockings as they are less effective. 2, 3

VTE Prophylaxis

• Consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 2

Aspiration Prevention

• Perform formal dysphagia screening before initiating oral intake to reduce the risk of pneumonia 2, 3
• Use soft sponges instead of toothbrushes for oral care in the first 24 hours to prevent trauma 1

Critical Pitfalls to Avoid

Be vigilant for early deterioration—over 20% of patients experience a decrease in Glasgow Coma Scale of 2 or more points between prehospital assessment and initial ED evaluation. 1, 2

Common Errors

• Do not delay imaging or treatment decisions while waiting for diagnostic test results 2, 3
• Monitor for hematoma expansion which occurs in 30-40% of patients; risk factors include "spot sign" on CT angiography, early presentation, anticoagulant use, and initial hematoma volume 2
• Do not transfer hypotensive patients who are actively bleeding—control hemorrhage before transfer 3
• Avoid automatic blood pressure cuffs on arms with antecubital venous access to prevent hematoma formation; check cuff site frequently and rotate every 2 hours 1
• Avoid invasive procedures such as arterial punctures, catheter insertion, or nasogastric tube placement in the first 24 hours after thrombolytic treatment 1

Temperature and Glucose Management

• Monitor body temperature and treat fever (temperature >38°C); investigate and treat sources of fever 1, 2
• Monitor and manage glucose levels as part of routine care 2