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

Management of Hemorrhagic Stroke

Immediate Emergency Assessment and Stabilization

Treat hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with expertise in hyperacute stroke management, as over 20% of patients deteriorate within the first few hours. 1, 2

Initial Assessment Protocol

• Perform rapid ABC assessment (airway, breathing, circulation) immediately upon arrival—do not delay for any reason 1, 2
• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and focal deficits 1, 2
• 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 1, 2, 3
• Order urgent blood work including complete blood count, coagulation status (INR, aPTT), and blood glucose 2, 3
• Evaluate medication history with specific focus on anticoagulant or antiplatelet therapy 2, 3
• Consider vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 2, 3

Blood Pressure Management

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. 4, 1, 3

• Monitor blood pressure every 15 minutes until stabilized 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 3
• For patients with intracerebral hemorrhage presenting with systolic BP ≥220 mmHg, acute reduction in systolic BP >70 mmHg from initial levels within 1 hour of commencing treatment is not recommended 4
• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 3

Reversal of Coagulopathy

Patients on warfarin with elevated INR must receive prothrombin complex concentrate plus intravenous vitamin K immediately—rapid reversal while limiting fluid volumes is critical. 1, 2

• Withhold warfarin immediately upon diagnosis 1
• 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 2, 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 1, 2, 3
• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours 1, 2, 3
• Maintain a nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable 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 1, 3
• Hyperventilation can be used as a temporizing measure for patients with herniation syndromes 3
• Corticosteroids are not recommended for management of cerebral edema and increased intracranial pressure 3

Fluid Management

• Use isotonic fluids to maintain hydration while preventing volume overload 2
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 2, 3
• Avoid Ringer's lactate, Ringer's acetate, and gelatins as they are hypotonic in terms of real osmolality 2
• Do not use albumin or other synthetic colloids in early management 2

Surgical Considerations

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

• Obtain prompt neurosurgical consultation for all ICH patients to evaluate potential surgical interventions 1, 2, 3
• Consider external ventricular drainage with intraventricular fibrinolysis for intraventricular hemorrhage, which promotes hematoma clearance, decreases mortality, and improves good functional outcomes 3
• Early surgery should be considered for patients with a Glasgow Coma Scale score 9-12 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
• Recurrent seizures should be treated as with any other acute neurological condition 2, 3
• Prophylactic administration of anticonvulsants is not recommended 2, 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 1, 3
• Consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 3
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 1, 2, 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 1, 3
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome; risk factors include presence of contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume 3
• 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 2