What is the optimal therapy for a patient with hemorrhagic stroke, particularly with regards to blood pressure management and prevention of further bleeding?

Hemorrhagic Stroke Therapy

For acute hemorrhagic stroke, immediately lower systolic blood pressure to 140-160 mmHg within 6 hours of symptom onset using intravenous labetalol or nicardipine, while avoiding drops exceeding 70 mmHg per hour to prevent hematoma expansion and optimize functional outcomes. 1

Blood Pressure Management: The Critical Intervention

Acute Phase Targets (First 6 Hours)

Target systolic blood pressure of 140-160 mmHg within 6 hours of symptom onset is the cornerstone of hemorrhagic stroke management. 1 This differs fundamentally from ischemic stroke, where permissive hypertension is standard—in hemorrhagic stroke, there is no ischemic penumbra requiring high perfusion pressures, making aggressive blood pressure reduction both safe and beneficial. 1

• Initiate treatment within 2 hours and reach target within 1 hour to effectively reduce hematoma expansion. 1
• Maintain mean arterial pressure <130 mmHg. 1
• Ensure cerebral perfusion pressure remains ≥60 mmHg at all times, especially if elevated intracranial pressure is present. 1

Pharmacological Approach

First-line agent: Intravenous labetalol 1, 2

• Dosing: 10-20 mg IV over 1-2 minutes, may repeat every 10 minutes 3
• Alternative: continuous infusion at 2-8 mg/min 3
• Maximum dose: 300 mg 3

Alternative agent: Nicardipine (particularly useful when labetalol is contraindicated due to severe bradycardia, heart block, severe asthma/COPD, or decompensated heart failure) 1

• Initial dose: 5 mg/hour IV infusion 1
• Titrate by increasing 2.5 mg/hour every 5 minutes 1
• Maximum: 15 mg/hour 1

Critical Safety Parameters

Avoid excessive blood pressure reduction—never drop systolic BP by more than 70 mmHg within the first hour, particularly in patients presenting with systolic BP ≥220 mmHg. 1, 2 This precipitous decline increases risk of acute renal injury, compromises cerebral perfusion, and is associated with increased mortality. 1

Use continuous smooth titration to minimize blood pressure variability, which is independently associated with poor outcomes regardless of mean blood pressure achieved. 1

Monitoring Requirements

Intensive Surveillance Protocol

• Blood pressure monitoring every 15 minutes until stabilized, then every 30-60 minutes for the first 24-48 hours. 1
• Neurological assessment using validated scales (NIH Stroke Scale) at baseline and hourly for the first 24 hours. 3, 1
• Continuous automated monitoring of oxygen saturation, arterial blood pressure, heart rhythm (1-lead ECG), body temperature, and intermittent blood glucose. 3
• Assessment for clinical signs of increased intracranial pressure. 1

Coagulopathy Reversal

For patients with intracranial bleeding during oral anticoagulation, immediately administer fresh frozen plasma or prothrombin complex concentrates according to available guidelines. 3 This represents one of the few evidence-based interventions beyond blood pressure control. 4

Surgical Considerations

Neurosurgical consultation should be obtained for:

• Cerebellar hemorrhage (surgical evacuation is indicated) 4
• Lobar intracerebral hemorrhage on a case-by-case basis, though the value of evacuation remains undefined based on STICH I trial results 3
• Access to hemicraniectomy 24/7 should be available either in-house or within 30 minutes 3

The evidence for surgical evacuation of supratentorial hemorrhages remains limited, and decisions should be individualized through neurosurgical consultation. 3

General Medical Management

Supportive Care Priorities

• Control fever aggressively according to stroke guidelines. 3
• Manage hyperglycemia with careful glucose monitoring. 3
• Maintain fluid balance to avoid both dehydration and fluid overload. 3
• Assess for dysphagia before allowing oral intake to prevent aspiration pneumonia. 3
• Implement venous thromboembolism prophylaxis once hemorrhage is stable. 3

Specialized Nursing Care

Stroke units must have specialized nursing dedicated to stroke patient care with formal training in stroke medicine. 3 Nursing priorities include:

• Careful positioning and handling with pressure-area risk evaluation 3
• Neurological monitoring using standardized scales 3
• Prevention and early detection of complications including aspiration pneumonia, deep venous thrombosis, pressure sores, and dehydration 3

Early Mobilization

Implement early mobilization according to the "out of bed within 24-hour principle" as soon as the stroke has stabilized and the patient's general medical condition permits. 3 This requires multiprofessional team services available 7 days per week. 3

Secondary Prevention

Initiate secondary stroke prevention as early as possible, preferably within the first 24 hours after admission. 3 After the acute phase (typically 3 days), target blood pressure <130/80 mmHg for long-term secondary prevention. 1

Common Pitfalls to Avoid

• Delaying blood pressure reduction beyond 6 hours—the therapeutic window for preventing hematoma expansion is narrow. 1
• Allowing blood pressure to remain above 160 mmHg systemically—this increases risk of hematoma expansion. 1
• Excessive blood pressure reduction (>70 mmHg in 1 hour)—associated with increased mortality and acute kidney injury. 1, 2
• Compromising cerebral perfusion pressure below 60 mmHg—may cause secondary brain injury even while controlling systemic blood pressure. 1
• Large blood pressure variability with peaks and fluctuations—worsens functional outcomes independent of mean blood pressure achieved. 1

Special Population: Multicompartmental Hemorrhage

For patients with multicompartmental hemorrhage and elevated intracranial pressure, consider ICP monitoring to guide blood pressure management and ensure cerebral perfusion pressure remains adequate. 1 Accept slightly higher systemic blood pressure targets if intracranial pressure is significantly elevated, balancing systemic control with maintenance of adequate cerebral perfusion. 1