What is the recommended acute treatment for a hemorrhagic stroke, including blood pressure control, anticoagulant reversal, surgical indications, intracranial pressure management, seizure prophylaxis, and secondary prevention?

Treatment for Hemorrhagic Stroke

For acute hemorrhagic stroke, immediately lower systolic blood pressure to 130-180 mmHg (ideally <140 mmHg if between 150-220 mmHg), reverse any coagulopathy with prothrombin complex concentrate plus IV vitamin K, and admit to an intensive care or dedicated stroke unit with neuroscience expertise. 1

Immediate Assessment and Stabilization

• Treat hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with hyperacute stroke expertise, as over 20% of patients deteriorate within the first few hours. 1
• Perform rapid ABC assessment (airway, breathing, circulation) immediately upon arrival. 1
• Conduct neurological examination using the NIHSS to determine focal deficits and stroke severity. 1
• Obtain immediate non-contrast CT scan to confirm diagnosis, location, and extent of hemorrhage—this is mandatory and should not be delayed. 1
• Consider CT angiography to identify the "spot sign" which predicts hematoma expansion risk. 1

Blood Pressure Management

This is one of the most critical acute interventions:

• For systolic BP 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg—this is safe and can improve functional outcomes. 1
• For systolic BP >180 mmHg, achieve immediate reduction to maintain systolic BP between 130-180 mmHg. 2
• Assess blood pressure every 15 minutes until stabilized. 1
• Labetalol is the first-line agent, with urapidil and nicardipine as useful alternatives. 2

The European Heart Journal guidelines specifically recommend immediate BP reduction for hemorrhagic stroke with systolic BP >180 mmHg, targeting systolic BP 130-180 mmHg. 2 This differs from ischemic stroke management where BP lowering is generally avoided.

Reversal of Coagulopathy

This must be done immediately:

• Patients on warfarin with elevated INR should receive prothrombin complex concentrate plus intravenous vitamin K immediately—rapid reversal while limiting fluid volumes is critical. 1
• For patients with intracranial bleeding during oral anticoagulation, use fresh frozen plasma or prothrombin complex concentrates according to available guidelines. 2

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
• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable. 1
• Monitor vital signs including temperature every 4 hours for the first 48 hours. 2

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to facilitate venous drainage. 1
• 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
• Perform ventriculostomy for patients with spontaneous ICH (with or without intraventricular hemorrhage) and symptomatic hydrocephalus. 1

Surgical Considerations

Surgery is indicated in specific circumstances:

• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. 1
• For supratentorial hemorrhages, surgical evacuation remains of unproven benefit for most patients, though well-selected cases may benefit. 3
• Neurosurgical consultation should be obtained for all hemorrhagic stroke patients to discuss potential surgical interventions. 2

Fluid Management

• Use isotonic fluids to maintain hydration while preventing volume overload. 1
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they worsen cerebral edema. 1

Temperature and Metabolic Management

• Monitor body temperature and treat fever (temperature >37.5°C or >38°C). 2, 1
• Investigate possible infections such as pneumonia or urinary tract infection when fever develops. 2
• Initiate antipyretic and antimicrobial therapy as required. 2
• Monitor and manage glucose levels as part of routine care. 1

Prevention of Venous Thromboembolism

• Implement intermittent pneumatic compression (IPC) for prevention of venous thromboembolism beginning the day of hospital admission. 1
• IPC should be applied as soon as possible and within the first 24 hours after admission. 2
• Do not use graduated compression stockings alone as they are less effective. 1
• Pharmacological VTE prophylaxis with low-molecular-weight heparin should be considered once the hemorrhage has stabilized and there is no contraindication. 2

Seizure Management

• New-onset seizures should be treated using appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting. 2
• Routine prophylactic anticonvulsants are not recommended but should be considered for patients with clinical or electrographic seizures. 2

Early Mobilization and Rehabilitation

• Perform initial assessment by rehabilitation professionals as soon as possible after admission, ideally within 48 hours. 2
• Begin rehabilitation therapy as early as possible once the patient is medically stable to participate. 2
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin once medically appropriate, but clinical judgment is essential given the risk of hematoma expansion. 2

Critical Pitfalls to Avoid

• Be vigilant for early deterioration—over 20% of patients experience significant decline between prehospital assessment and initial ED evaluation. 1
• Monitor for hematoma expansion which occurs in 30-40% of patients; risk factors include "spot sign" on CT angiography, early presentation, anticoagulant use, and initial hematoma volume. 1
• Avoid aggressive BP lowering in patients not meeting the specified criteria, as this may worsen outcomes. 2
• Do not delay coagulopathy reversal—this must be done immediately upon diagnosis. 1