In a patient with acute intracerebral hemorrhagic stroke, should Nurokind Gold (multivitamin‑mineral supplement) be given routinely as part of management?

Nurokind Gold Should Not Be Given Routinely in Acute Hemorrhagic Stroke

Multivitamin-mineral supplements like Nurokind Gold have no established role in the acute management of intracerebral hemorrhagic stroke and should not be administered routinely. There is no evidence that vitamin supplementation improves mortality, morbidity, or quality of life outcomes in hemorrhagic stroke patients.

Evidence Against Routine Vitamin Supplementation in Stroke

Lack of Benefit in Stroke Prevention and Treatment

The available guideline evidence addresses vitamin supplementation primarily in the context of stroke prevention and ischemic stroke, with no support for routine use:

• The 2024 American Heart Association/American Stroke Association guidelines found that multivitamins did not reduce stroke risk in large randomized trials. In a study of 14,641 male physicians taking Centrum Silver versus placebo over 11.2 years, multivitamins showed no reduction in stroke incidence 1.

• B-complex vitamin therapy (including B6, B12, and folate) failed to reduce cardiovascular outcomes including stroke in patients with established vascular disease, despite lowering homocysteine levels 1.

• The 2006 AHA/ASA guidelines concluded there is no evidence that reducing homocysteine levels with vitamins leads to stroke recurrence reduction, though daily standard multivitamin preparations were considered reasonable given low cost and safety 1.

• The VITATOPS trial (8,164 patients with recent stroke or TIA) found that daily B vitamins (folic acid 2 mg, B6 25 mg, B12 0.5 mg) did not reduce major vascular events compared to placebo (risk ratio 0.91,95% CI 0.82-1.00, p=0.05), with no support for using B vitamins to prevent recurrent stroke 2.

Specific Concerns with Vitamin E in Hemorrhagic Stroke

• Vitamin E supplementation increased the risk of subarachnoid hemorrhage (relative risk 2.45,95% CI 1.08-5.55) in hypertensive men in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study 3.

• This finding is particularly relevant because vitamin E is a component of many multivitamin formulations and could theoretically worsen bleeding risk in hemorrhagic stroke patients 3.

What Should Be Done Instead in Hemorrhagic Stroke

Acute Management Priorities

The focus in acute intracerebral hemorrhage should be on evidence-based interventions that affect mortality and morbidity:

• Blood pressure management targeting systolic BP 130-150 mmHg using rapid-onset, short-duration agents, as elevated blood pressure is associated with hematoma expansion 4.

• Reversal of anticoagulation if present (e.g., warfarin-induced ICH requires 4-factor PCC plus vitamin K 5-10 mg IV) 4, 5.

• Early dysphagia screening and appropriate nutritional support for patients who cannot swallow safely 1.

• Early enteral nutrition is suggested for stroke patients (ischemic or hemorrhagic) when indicated, but this refers to standard nutritional support, not vitamin supplementation 1.

Nutritional Support Guidelines

• The 2018 ESPEN guidelines recommend against routine oral nutritional supplements (ONS) for acute stroke patients without dysphagia who are adequately nourished on admission 1.

• ONS are recommended only for stroke patients identified as malnourished or at risk of malnutrition, with individualized nutrition care plans developed by nutrition specialists 1.

Critical Pitfalls to Avoid

• Do not confuse vitamin supplementation with evidence-based nutritional support. Standard enteral nutrition for malnourished patients is different from giving multivitamin supplements to all hemorrhagic stroke patients 1.

• Avoid the assumption that "vitamins can't hurt." Vitamin E has been associated with increased hemorrhagic stroke risk in certain populations 3.

• Do not delay proven interventions (blood pressure control, anticoagulation reversal, dysphagia screening) to administer unproven vitamin supplements 1, 4.

• Recognize that Nurokind Gold contains B-complex vitamins similar to those studied in VITATOPS, which showed no benefit in preventing vascular events after stroke 2.

When Vitamin K Is Indicated (The Exception)

The only vitamin with a specific role in hemorrhagic stroke management is vitamin K for warfarin reversal:

• For warfarin-induced intracranial hemorrhage, administer vitamin K 5-10 mg IV by slow infusion plus 4-factor PCC to achieve rapid INR correction and improve survival 4, 5.

• This is a specific therapeutic indication for vitamin K, not a rationale for general multivitamin supplementation 4, 5.