Immediate Management of Hemorrhagic Stroke

Initial Assessment and Stabilization

The American College of Cardiology recommends treating hemorrhagic stroke as a medical emergency requiring immediate evaluation by physicians with expertise in hyperacute stroke management 1
Perform rapid assessment of airway, breathing, and circulation (ABCs) immediately upon arrival 1
Conduct neurological examination to determine focal deficits and assess stroke severity using standardized scales such as the National Institutes of Health Stroke Scale (NIHSS) 1
Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage 1
Order urgent blood work including complete blood count, coagulation status, and blood glucose 1
Evaluate medication history, particularly focusing on anticoagulant or antiplatelet therapy 1
Consider vascular imaging to exclude underlying lesions such as aneurysms or arteriovenous malformations 1

Monitor blood pressure every 15 minutes until stabilized 1
For patients with systolic blood pressure between 150-220 mmHg, acute lowering to 140 mmHg is safe and can improve functional outcomes 1
Use small boluses of labetalol for hypertension management 2
After correcting hypovolemia or excess sedation, manage hypotension with small boluses of an α-agonist followed by an infusion 2

Rapidly reverse anticoagulation while limiting fluid volumes 2
For patients on warfarin with elevated INR, administer prothrombin complex concentrate plus intravenous vitamin K 2, 1
Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1

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 3, 2
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

Treat new-onset seizures occurring within 24 hours of stroke onset with appropriate short-acting medications 1
Single, self-limiting seizures at onset or within 24 hours should not receive long-term anticonvulsant medications 1
Recurrent seizures should be treated as with any other acute neurological condition 3
Prophylactic administration of anticonvulsants is not recommended 3

Elevate the head of the bed by 20-30 degrees to help venous drainage 3
Treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 3
Avoid antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 3
Consider osmotherapy for patients whose condition is deteriorating due to increased intracranial pressure 3

Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 1
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
Consider surgical decompression and evacuation of large cerebellar infarctions leading to brain stem compression and hydrocephalus 3

Provide initial monitoring and management in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1
Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 1
Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1
Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 1

Be vigilant for early deterioration, which is common in the first few hours after ICH onset 1
Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome 1
Avoid delaying imaging or treatment decisions while waiting for diagnostic test results 1
Do not transfer patients who are hypotensive and actively bleeding; control hemorrhage before transfer 2
Avoid permissive hypotension during resuscitation of multiply-injured patients with traumatic brain injury except in exceptional circumstances 2