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

Initial Management of Hemorrhagic Stroke

For patients presenting with hemorrhagic stroke, immediately stabilize ABCs, obtain non-contrast CT within minutes, lower systolic blood pressure to 140 mmHg if presenting between 150-220 mmHg, reverse any coagulopathy with prothrombin complex concentrate plus IV vitamin K, and admit to an ICU or dedicated stroke unit with hourly neurological assessments for the first 24 hours. 1, 2, 3

Immediate Assessment and Stabilization (First 15 Minutes)

• Treat as a medical emergency requiring immediate evaluation by physicians with hyperacute stroke expertise, as over 20% of patients deteriorate within the first few hours 1, 2, 3
• Perform rapid ABC assessment (airway, breathing, circulation) immediately upon arrival—do not delay for any reason 1, 2, 3
• Obtain non-contrast CT scan immediately to confirm diagnosis, location, and extent of hemorrhage—this 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, 3

Blood Pressure Management (Within First Hour)

• Monitor blood pressure every 15 minutes until stabilized 1, 2, 3
• For systolic BP 150-220 mmHg without contraindications, acutely lower to 140 mmHg—this is safe and improves functional outcomes 1, 2, 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 2, 3
• Avoid sodium nitroprusside in patients with markedly elevated intracranial pressure as it induces cerebral vasodilation 1, 3

Urgent Laboratory and Imaging Workup

• Order urgent blood work: complete blood count, coagulation status (INR, aPTT), and blood glucose 1, 3
• Evaluate medication history focusing specifically on anticoagulant or antiplatelet therapy 1, 3
• Obtain vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 1, 3

Reversal of Coagulopathy (Immediate Priority)

• For warfarin patients with elevated INR: administer prothrombin complex concentrate plus intravenous vitamin K immediately—rapid reversal while limiting fluid volumes is critical 1, 2, 3
• Withhold warfarin immediately upon diagnosis 2
• For severe coagulation factor deficiency or severe thrombocytopenia: administer appropriate factor replacement therapy or platelets 1, 3

Monitoring and Care Setting

• Admit to intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1, 2, 3
• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1, 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
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome 1, 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 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 1, 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 surgical decompression and evacuation of large cerebellar infarctions leading to brain stem 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, 2, 3
• Do not treat single, self-limiting seizures at onset or within 24 hours with long-term anticonvulsant medications 1, 2, 3
• Treat recurrent seizures as with any other acute neurological condition 1, 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 1, 2, 3
• Do not use graduated compression stockings as they are less effective than intermittent pneumatic compression 2, 3
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 1, 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

Critical Pitfalls to Avoid

• Do not delay imaging or treatment decisions while waiting for diagnostic test results 1, 2, 3
• Do not transfer patients who are hypotensive and actively bleeding—control hemorrhage before transfer 1
• Avoid permissive hypotension during resuscitation of multiply-injured patients with traumatic brain injury except in exceptional circumstances 1