From the Guidelines
Management of Ischemic Stroke with Subarachnoid and Cerebellar Hemorrhage
The management of ischemic stroke with subarachnoid and cerebellar hemorrhage should prioritize surgical evacuation for cerebellar hemorrhage with neurological deterioration, brainstem compression, and/or hydrocephalus, as well as careful blood pressure management to balance the risks of rebleeding and delayed cerebral ischemia 1.
- Cerebellar Hemorrhage: Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence B) 1.
- Blood Pressure Management: Blood pressure elevations often complicate the management of intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage, and controversies persist over the timing, mechanisms, and approaches to treatment 1.
- Subarachnoid Hemorrhage: BP control is even more complex for subarachnoid hemorrhage, where there are rationales for both BP lowering and elevation in reducing the risks of rebleeding and delayed cerebral ischemia, respectively 1.
- Ischemic Stroke: The management of ischemic stroke with subarachnoid and cerebellar hemorrhage should also consider hyperacute stroke care guidelines, including updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage 1.
In terms of specific treatments, minimally invasive approaches for evacuation of supratentorial ICHs and intraventricular hemorrhages have demonstrated reductions in mortality, but the clinical trial evidence for improvement of functional outcome with these procedures is neutral 1. Additionally, prophylactic corticosteroids or continuous hyperosmolar therapy appears to have no benefit for outcome, whereas the use of platelet transfusions outside the setting of emergency surgery or severe thrombocytopenia appears to worsen outcome 1.
From the Research
Management of Ischemic Stroke with Subarachnoid and Cerebellar Hemorrhage
- The management of ischemic stroke with subarachnoid and cerebellar hemorrhage involves early identification and treatment of the bleeding source, as well as management of patients in a neurocritical care unit with blood pressure control, euvolemia, and frequent monitoring for neurologic and systemic complications 2, 3.
- Admission of patients to high-volume centers under the management of a specialized and multidisciplinary team is also recommended 2, 3.
- Treatment of symptomatic cerebral vasospasm/delayed cerebral ischemia with induced hypertension and endovascular therapies is also an important aspect of management 2, 3.
- In the emergency department, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure, followed by CT angiography of the head or a lumbar puncture if further investigation is needed 4.
- Early intervention in the emergency department is crucial in improving stroke outcome, and current emergency evaluation and management of ischemic stroke, intracerebral hemorrhage, cerebellar stroke, subarachnoid hemorrhage, and transient ischemic attacks should be discussed 5.
- Each stroke subtype has varying premorbid-related and ictus-related outcome predictive models that have differing sensitivities and specificities, and common themes in management advocate for early interventions to reduce morbidity and mortality 6.