What are the initial management guidelines for a patient presenting with a hemorrhagic stroke, particularly those with a history of atrial fibrillation or other cardiac conditions?

Hemorrhagic Stroke: Initial Management Guidelines

Immediate Stabilization and Airway Management

For patients presenting with hemorrhagic stroke, particularly those with atrial fibrillation or cardiac conditions, immediate assessment and stabilization of airway, breathing, and circulation takes priority, with oxygen supplementation only for hypoxemic patients (oxygen saturation <94%). 1

• Assess the patient within 10 minutes of ED arrival and secure IV access immediately 1
• Administer oxygen only if oxygen saturation is below 94%; routine oxygen therapy for non-hypoxic patients is not recommended 1, 2
• Obtain baseline blood samples including complete blood count, coagulation studies (INR, aPTT), and blood glucose 1
• Identify and urgently correct hypoglycemia, as elevated glucose is associated with poor outcomes 2

Blood Pressure Management in Hemorrhagic Stroke

In hemorrhagic stroke, aggressive blood pressure reduction to systolic BP <140 mmHg is generally well tolerated and recommended, as there is no perihematomal penumbra requiring elevated perfusion pressure. 3

• Target systolic BP reduction to 140 mmHg, as lower targets show no additional functional benefit but increase renal complications 3
• This differs fundamentally from ischemic stroke management, where BP is typically left untreated unless >220/120 mmHg 1, 3
• Use IV labetalol (10-20 mg over 1-2 minutes) or nicardipine infusion (5 mg/hr, titrate by 2.5 mg/hr every 5-15 minutes) for acute BP control 1

Neuroimaging and Diagnosis

Emergent non-contrast CT scan of the brain is the essential first diagnostic step to distinguish hemorrhagic from ischemic stroke and must not be delayed. 1

• CT scan takes priority over ECG or other diagnostic tests 1
• Clinical findings alone cannot definitively distinguish hemorrhagic from ischemic stroke, despite certain features increasing probability: coma (LR 6.2), neck stiffness (LR 5.0), seizures (LR 4.7), diastolic BP >110 mmHg (LR 4.3), vomiting (LR 3.0), and headache (LR 2.9) 4
• 20% of stroke patients have diagnostically unhelpful clinical presentations requiring neuroimaging for certainty 4

Cardiac Monitoring and Assessment

Continuous cardiac monitoring for at least 24-48 hours is essential to detect atrial fibrillation and potentially life-threatening arrhythmias. 1, 2

• Obtain 12-lead ECG to identify atrial fibrillation or recent myocardial infarction as potential embolic sources, though this does not take priority over CT imaging 1
• Hemodynamically stable patients with asymptomatic arrhythmias (bradycardia, premature contractions, AV block) may not require immediate treatment 1

Anticoagulation Reversal in Hemorrhagic Stroke

For patients with hemorrhagic stroke on anticoagulation, immediate reversal is critical to prevent hematoma expansion, which occurs in approximately one-third of cases and significantly worsens outcomes. 5

For Warfarin:

• Administer IV vitamin K and prothrombin complex concentrate (PCC) or fresh frozen plasma to rapidly reverse INR 6
• Target INR <1.4 urgently 6

For Direct Oral Anticoagulants (DOACs):

• Consider specific reversal agents if available (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1
• Warfarin-associated hemorrhagic transformation carries particularly poor prognosis with higher morbidity and mortality 6

Neurological Assessment and Monitoring

Perform validated neurological scale assessment (NIHSS) at baseline and repeat hourly for the first 24 hours, as early deterioration occurs in 25% of stroke patients. 2

• Admit to dedicated stroke unit or neurocritical care unit, which improves outcomes (Level I evidence) 2
• Maintain low threshold for repeat imaging if clinical worsening occurs: one-third from stroke progression, one-third from cerebral edema, 10% from hemorrhage expansion, and 11% from recurrent ischemia 2

Venous Thromboembolism Prophylaxis

For hemorrhagic stroke patients with restricted mobility, initiate prophylactic-dose subcutaneous heparin (UFH or LMWH) between days 2-4, or use intermittent pneumatic compression devices. 1

• Prophylactic-dose LMWH is preferred over UFH (Grade 2B) 1
• Avoid elastic compression stockings (Grade 2B) 1
• Patients preferring to avoid theoretical rebleeding risk with heparin should receive mechanical prophylaxis with intermittent pneumatic compression 1

Critical Pitfall: Distinguishing Hemorrhagic from Ischemic Stroke Management

The management of hemorrhagic stroke fundamentally differs from ischemic stroke—thrombolytics and anticoagulants are absolutely contraindicated in hemorrhagic stroke, while aggressive BP reduction is beneficial. 1, 3

• Systemic thrombolysis with rtPA is contraindicated in patients with hemorrhagic stroke or those on therapeutic anticoagulation 1
• For ischemic stroke, rtPA can be given if INR <1.7 for warfarin patients, but this does not apply to hemorrhagic stroke 1

Glucose Management

Measure serum glucose immediately and correct hypoglycemia urgently; maintain glucose <300 mg/dL (<16.63 mmol/L) as hyperglycemia is associated with poor outcomes. 2

Progressing Hemorrhagic Stroke Recognition

Monitor for acute progression (hematoma expansion, intraventricular hemorrhage, perihaematomal edema), subacute progression (second peak of edema at days 5-14), and chronic progression (encapsulated hematoma). 5

• Acute progression requires primarily conservative management 5
• Subacute and chronic progression may require surgical intervention 5
• Hematoma expansion is a primary cause of early deterioration and worse outcomes 5

Anticoagulation Resumption After Hemorrhagic Stroke

For patients with atrial fibrillation who require long-term anticoagulation, resumption can be considered after 4-8 weeks, particularly when the bleeding cause or risk factor has been treated. 1

• Multidisciplinary decision required with input from stroke physicians, neurologists, cardiologists, neuroradiologists, and neurosurgeons 1
• Consider anticoagulants with lower bleeding risk (NOACs preferred over warfarin) 1
• Balance ischemic stroke risk (particularly high with mechanical heart valves or CHADS₂ score ≥4) against recurrent hemorrhage risk 1