What are the management strategies for hemorrhagic stroke?

Hemorrhagic Stroke Management

Immediate Emergency Assessment and Stabilization

Treat hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with expertise in hyperacute stroke management, as over 20% of patients deteriorate within the first few hours. 1, 2

Initial Actions Upon Arrival

• Perform rapid ABC assessment (airway, breathing, circulation) immediately—do not delay for any reason 1, 3
• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and focal deficits 1, 2
• Obtain immediate non-contrast CT scan to confirm diagnosis, location, and extent of hemorrhage—this is mandatory and takes priority over all other diagnostic tests 1, 2
• Order urgent blood work: complete blood count, coagulation status (INR, aPTT), and blood glucose 1, 3
• Obtain detailed medication history with specific focus on anticoagulants (warfarin, DOACs) and antiplatelet agents 1, 3
• Perform vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying aneurysms or arteriovenous malformations 1

Blood Pressure Management

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

• Monitor blood pressure every 15 minutes until stabilized 1, 3
• 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 markedly elevated intracranial pressure as it induces cerebral vasodilation 1, 2
• For hypotension after correcting hypovolemia or excess sedation, use small boluses of an α-agonist followed by infusion 3

Reversal of Coagulopathy

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

• Withhold warfarin immediately upon diagnosis 1
• Administer prothrombin complex concentrate as first-line therapy for warfarin reversal 2, 3
• Give intravenous vitamin K concurrently with factor replacement 1, 3
• Patients with severe thrombocytopenia should receive platelet transfusions 1, 3
• Patients with severe coagulation factor deficiency require appropriate factor replacement therapy 1, 3

Monitoring and Care Setting

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

• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours 1, 3
• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable 2
• Monitor for hematoma expansion, which occurs in 30-40% of patients and predicts poor outcome 1, 2
• Risk factors for hematoma expansion include "spot sign" on CT angiography, early presentation (<3 hours), anticoagulant use, and large initial hematoma volume 1, 2

Management of Increased Intracranial Pressure

• Elevate head of bed 20-30 degrees to facilitate venous drainage 1, 2, 3
• Treat all factors that exacerbate raised intracranial pressure: hypoxia, hypercarbia, and hyperthermia 1, 2
• 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 1, 2
• Use hyperventilation only as a temporizing measure for patients with herniation syndromes 1
• Do not use corticosteroids for management of cerebral edema and increased intracranial pressure—they are ineffective 4, 1, 2

Fluid Management

• Use isotonic fluids to maintain hydration while preventing volume overload 2, 3
• Avoid hypo-osmolar fluids such as 5% dextrose in water—they worsen cerebral edema 1, 2, 3
• 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

Surgical Considerations

Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction must undergo surgical removal of the hemorrhage as soon as possible. 1, 2, 3

• Obtain prompt neurosurgical consultation for all ICH patients to evaluate potential surgical interventions 1, 3
• Consider early surgery for patients with Glasgow Coma Scale score 9-12 4, 1
• Perform ventriculostomy for patients with spontaneous ICH (with or without intraventricular hemorrhage) and symptomatic hydrocephalus 2
• Surgical decompression is recommended for large cerebellar infarctions leading to brainstem compression and hydrocephalus 1, 3

Seizure Management

• Treat new-onset seizures occurring within 24 hours of stroke onset with short-acting medications (e.g., lorazepam IV) if not self-limited 1, 3
• Do not treat single, self-limiting seizures at onset or within 24 hours with long-term anticonvulsant medications 1, 3
• Treat recurrent seizures as with any other acute neurological condition 1, 2, 3
• Do not use prophylactic anticonvulsants in patients who have not had seizures 1, 3

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. 4, 1, 2, 3

• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 1, 3
• 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 1
• Monitor body temperature and treat fever (>38°C); investigate and treat sources of fever 2
• Monitor and manage glucose levels as part of routine care 2

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, 3
• Do not delay imaging or treatment decisions while waiting for diagnostic test results 1, 3
• Do not transfer patients who are hypotensive and actively bleeding; control hemorrhage before transfer 3
• Blood pressure targets require aggressive monitoring and management—failure to achieve targets is associated with worse outcomes 1
• Hematoma expansion occurs in 30-40% of patients within the first few hours and is the most important modifiable predictor of poor outcome 1, 2