From the Guidelines
Minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration, with or without thrombolytic use, is recommended as a safe and potentially useful treatment to reduce mortality in patients with hemorrhagic stroke, particularly those with moderate to large intracerebral hemorrhages 1.
Key Considerations
- The treatment of hemorrhagic stroke requires immediate emergency medical care, with a focus on stabilizing the patient and controlling blood pressure.
- Medications like mannitol or hypertonic saline may be given to reduce brain swelling.
- Reversal of blood thinners, such as warfarin, using vitamin K, prothrombin complex concentrate, or fresh frozen plasma, is crucial in patients taking these medications.
- For patients on newer anticoagulants like dabigatran, specific reversal agents like idarucizumab may be used.
- Surgical intervention, including minimally invasive hematoma evacuation, may be necessary to remove blood and relieve pressure on the brain.
Management of Blood Pressure
- Blood pressure is carefully managed, often with medications like labetalol or nicardipine, aiming for systolic pressure below 140-160 mmHg 1.
- This careful management is crucial because hemorrhagic strokes involve bleeding in the brain, which creates pressure that damages brain tissue.
Rehabilitation
- Recovery involves rehabilitation, including physical, occupational, and speech therapy, which should begin as soon as the patient is stable.
- The goal of rehabilitation is to improve functional outcomes and quality of life for patients with hemorrhagic stroke.
Important Considerations
- Clot-busting medications like tPA are contraindicated in hemorrhagic strokes, as they would worsen bleeding.
- The treatment of hemorrhagic stroke requires a multidisciplinary approach, involving emergency medical services, neurologists, neurosurgeons, and rehabilitation specialists.
From the Research
Treatment of Hemorrhagic Stroke
- The treatment of hemorrhagic stroke involves control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage 2.
- Evidence-based guidelines exist for the treatment of intracerebral hemorrhage (ICH), which is the most common type of hemorrhagic stroke 2.
- The treatment approach may vary depending on the individual patient's condition, and factors such as blood pressure targets, reversal strategies for anticoagulant medications, and the role of minimally invasive surgery are still being researched 2.
Mechanical Ventilation
- Mechanical ventilation may be necessary for patients with severe stroke, including those with hemorrhagic stroke, due to neurological deterioration, pulmonary complications, or elective intubation for procedures and surgery 3, 4, 5.
- The prognosis for stroke patients requiring mechanical ventilation is generally poor, with a 1-year survival rate of around 23% 5.
- Factors that influence outcome in ventilated stroke patients include age, Glasgow Coma Scale (GCS) score, indication for intubation, and presence of brainstem dysfunction 3, 4, 5.
Surgical Interventions
- Surgical evacuation of cerebellar hemorrhage is a recommended treatment approach for hemorrhagic stroke 2.
- Minimally invasive surgery may also be considered for select patients, although its role is still being researched 2, 6.
- Decompressive hemicraniectomy may be necessary for patients with large vessel occlusion and contralateral intracranial hemorrhage, although this is a complex and high-risk procedure 6.