What medications should be given to a patient with a hemorrhagic stroke?

Medications for Hemorrhagic Stroke

Blood Pressure Management

For hemorrhagic stroke, intravenous nicardipine is the preferred agent to lower systolic blood pressure to a target of 140-179 mm Hg, with initiation as soon as possible after presentation. 1

Acute Blood Pressure Control Protocol

• Start nicardipine at 5 mg/hour IV and titrate by 2.5 mg/hour every 5-15 minutes to a maximum of 15 mg/hour to achieve target systolic BP of 140-179 mm Hg 2, 3
• Nicardipine achieves goal BP in nearly 100% of patients, with 89% reaching target within 60 minutes of initiation 3
• Nicardipine provides superior BP control compared to labetalol, with less BP variability and better maintenance within goal range 3
• Avoid intensive BP lowering to <140 mm Hg systolic, as the ATACH-2 trial (2016) demonstrated no benefit and increased renal adverse events (9.0% vs 4.0%) with intensive targets of 110-139 mm Hg compared to standard targets of 140-179 mm Hg 1

Alternative Blood Pressure Agents

• Labetalol 10-20 mg IV over 1-2 minutes can be used if nicardipine is unavailable, though it achieves goal BP in only 61% of patients and requires more rescue antihypertensives 2, 3
• Labetalol is associated with more rebound hypertension (75.9% vs 40%) and bradycardia (44.8% vs 23.3%) compared to nicardipine 4

Blood Pressure Monitoring

• Monitor BP every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 2
• Frequent monitoring is critical as BP is a dynamic parameter requiring identification of trends and extreme fluctuations 2

Venous Thromboembolism Prophylaxis

Initiate prophylactic-dose low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) subcutaneously between days 2-4 after hemorrhagic stroke. 5

VTE Prevention Protocol

• LMWH is preferred over UFH for VTE prophylaxis (Grade 2B recommendation) 5
• Start VTE prophylaxis ideally within 24 hours of admission after ruling out intracranial hemorrhage, but typically between days 2-4 for hemorrhagic stroke 5, 6
• Use intermittent pneumatic compression devices if anticoagulation is contraindicated 5
• Avoid elastic compression stockings as they are not recommended for VTE prophylaxis (Grade 2B recommendation) 5

Medications to AVOID in Hemorrhagic Stroke

Neuroprotective Agents

• Do not use edaravone - insufficient data to support its use in hemorrhagic stroke despite free radical scavenging properties 5
• Do not use citicoline - the ICTUS trial showed no benefit in ischemic stroke (OR 1.03,95% CI 0.86-1.25), and there is no validation for hemorrhagic stroke 5

Antiplatelet and Anticoagulant Therapy

• Antiplatelet therapy is NOT routinely recommended for hemorrhagic stroke and should only be carefully considered if there is a strong indication (e.g., recent coronary stent) 2
• Do not initiate aspirin, clopidogrel, or other antiplatelet agents acutely after hemorrhagic stroke 2
• Avoid oral anticoagulants unless there is an overwhelming indication that outweighs bleeding risk 2

Long-Term Blood Pressure Management (After Acute Phase)

• Target BP <140/90 mm Hg for long-term management after hemorrhagic stroke (<130/80 mm Hg in younger patients, <140/80 mm Hg in elderly) 2
• First-line agents include RAS blockers (ACE inhibitors or ARBs), calcium channel blockers, and diuretics 2
• Restart or initiate long-term antihypertensive therapy after the initial 24 hours from stroke onset in most patients 2

Critical Pitfalls to Avoid

• Do not lower BP too aggressively - intensive lowering to <140 mm Hg systolic increases renal complications without improving outcomes 1
• Do not use lipid-lowering therapy or antiplatelet agents as routine secondary prevention after hemorrhagic stroke, unlike ischemic stroke where these are standard 2, 7
• Do not extrapolate ischemic stroke management to hemorrhagic stroke - the pathophysiology and treatment priorities differ fundamentally 5
• Do not delay VTE prophylaxis indefinitely - balance bleeding risk against thrombotic risk, typically starting between days 2-4 5