What is the treatment for a hemorrhagic stroke?

Treatment of Hemorrhagic Stroke

Hemorrhagic stroke must be treated as a medical emergency with immediate evaluation by physicians with expertise in hyperacute stroke management, focusing on rapid blood pressure control, reversal of coagulopathy, and prevention of hematoma expansion. 1, 2

Immediate Assessment and Stabilization

Perform rapid ABC assessment (airway, breathing, circulation) immediately upon patient arrival. 1, 2 Early deterioration occurs in over 20% of patients within the first few hours, making urgent evaluation critical. 2, 3

• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and stroke severity 1, 2
• Obtain immediate non-contrast CT scan to confirm diagnosis, location, and extent of hemorrhage—this is mandatory and should not be delayed 2, 3
• Order urgent blood work including complete blood count, coagulation status (INR, aPTT), and random glucose 3
• Evaluate medication history, particularly anticoagulant or antiplatelet therapy 3
• Consider vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 3

Blood Pressure Management

For patients with systolic blood pressure between 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg—this is safe and can improve functional outcomes. 1, 2, 3 This recommendation is supported by recent trial data showing decreased odds of poor functional outcome in hemorrhagic stroke patients with early blood pressure reduction. 4

• Monitor blood pressure every 15 minutes until stabilized 1, 3
• Use small boluses of labetalol for hypertension management, or consider nicardipine which is superior to labetalol for achieving and maintaining goal blood pressure 1, 3
• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 3
• After correcting hypovolemia or excess sedation, manage hypotension with small boluses of an α-agonist followed by an infusion 1

Reversal of Coagulopathy

Rapidly reverse anticoagulation while limiting fluid volumes—this is critical for preventing hematoma expansion. 1, 2

• For patients on warfarin with elevated INR, immediately administer prothrombin complex concentrate plus intravenous vitamin K 1, 2, 3
• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1, 3
• Withhold anticoagulant medications immediately 3

Common pitfall: Hematoma expansion occurs in 30-40% of patients and is a predictor of poor outcome; risk factors include presence of contrast extravasation ("spot sign" on CT angiography), early presentation, anticoagulant use, and initial hematoma volume. 2, 3

Fluid Management

Use isotonic fluids to maintain hydration while preventing volume overload. 1, 2

• Avoid hypo-osmolar fluids such as 5% dextrose in water as 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 1
• Do not use albumin or other synthetic colloids in early management 1
• Mild restriction of fluids is recommended to help manage brain edema 3

Management of Increased Intracranial Pressure

Elevate the head of the bed by 20-30 degrees to facilitate venous drainage. 1, 2, 3

• Treat all factors that exacerbate raised intracranial pressure including 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
• Surgical interventions, including drainage of cerebrospinal fluid, can be used to treat increased intracranial pressure secondary to hydrocephalus 3
• Do not use corticosteroids for management of cerebral edema and increased intracranial pressure—they are not recommended 3

Surgical Considerations

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

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 1, 3
• Consider surgical decompression and evacuation of large cerebellar infarctions leading to brain stem compression and hydrocephalus 1, 3
• Perform ventriculostomy for patients with spontaneous ICH (with or without IVH) and symptomatic hydrocephalus 2
• Consider early surgery for patients with a Glasgow Coma Scale score 9-12 3

For intraventricular hemorrhage specifically, external ventricular drainage with intraventricular fibrinolysis promotes hematoma clearance, decreases mortality (22.4% vs. 40.9% without IVF), improves good functional outcomes (47.2% vs. 38.3%), and reduces catheter occlusion rates (10.6% vs. 37.3%). 5

Seizure Management

Treat new-onset seizures occurring within 24 hours of stroke onset with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited. 1, 3

• A single, self-limiting seizure at onset or within 24 hours should not receive long-term anticonvulsant medications 1, 3
• Recurrent seizures should be treated as with any other acute neurological condition 1, 3
• Do not use prophylactic anticonvulsants in patients who have not had seizures—this is not recommended 1, 3

Monitoring and Care Setting

Initial monitoring and management must take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise. 1, 2, 3

• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable 5
• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1, 3
• Monitor body temperature and treat fever (temperature >38°C); investigate and treat sources of fever 2
• Monitor and manage glucose levels as part of routine care 2

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 for VTE prevention 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
• Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1, 3

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 2, 3
• Do not delay imaging or treatment decisions while waiting for diagnostic test results 3
• Do not transfer patients who are hypotensive and actively bleeding; control hemorrhage before transfer 1
• Avoid permissive hypotension during resuscitation except in exceptional circumstances 1
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 3