What is the initial management for a patient presenting with hemorrhagic stroke?

Initial Management of Hemorrhagic Stroke

Treat hemorrhagic stroke as a medical emergency requiring immediate ABC assessment, urgent non-contrast CT scan, blood pressure reduction to systolic 140 mmHg (if presenting BP 150-220 mmHg), and rapid reversal of any coagulopathy with prothrombin complex concentrate plus IV vitamin K for warfarin patients. 1, 2

Immediate Assessment and Stabilization (First 15 Minutes)

Perform rapid ABC assessment immediately upon arrival—do not delay for any reason. 2 This takes absolute priority over all other interventions.

• 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 2, 3
• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and focal deficits 1, 2
• Order urgent blood work including complete blood count, coagulation status (INR, aPTT), and blood glucose 1, 3
• Obtain medication history with specific focus on anticoagulant or antiplatelet therapy 1, 3

Critical pitfall: Over 20% of patients deteriorate within the first few hours, with hematoma expansion occurring in 30-40% of cases 2, 3. Do not delay imaging or treatment decisions while waiting for additional diagnostic test results 2, 3.

Blood Pressure Management (Within First Hour)

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. 2, 3 This recommendation comes from the American Heart Association and American College of Cardiology guidelines.

• Monitor blood pressure every 15 minutes until stabilized 1, 2
• 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 2, 3
• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 1, 3

The evidence strongly supports this aggressive BP reduction strategy, as research demonstrates no perihematomal penumbra in ICH patients, making rapid BP reduction well tolerated without risk of neurological worsening 4.

Reversal of Coagulopathy (Immediate Priority)

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 2
• Administer prothrombin complex concentrate as first-line therapy for warfarin reversal 1, 2
• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 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. 2, 3

• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours 2, 3
• 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 2, 3

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, 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, 3
• Hyperventilation can be used as a temporizing measure for patients with herniation syndromes 3
• Do not use corticosteroids for management of cerebral edema and increased intracranial pressure—they are not recommended 3

Fluid Management

• Use isotonic fluids to maintain hydration while preventing volume overload 1
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 1, 3
• Avoid Ringer's lactate, Ringer's acetate, and gelatins as they are hypotonic in terms of real osmolality 1
• Do not use albumin or other synthetic colloids in early management 1

Surgical Considerations

Obtain prompt neurosurgical consultation for all ICH patients to evaluate potential surgical interventions. 2, 3

• 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
• Consider vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 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 2, 3
• Do not treat single, self-limiting seizures at onset or within 24 hours with long-term anticonvulsant medications 2, 3
• Recurrent seizures should be treated as with any other acute neurological condition 1, 3
• Prophylactic administration of anticonvulsants is not recommended 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 2, 3
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 2, 3
• Consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 3