Initial Management of Hemorrhagic Stroke

Initial Assessment and Stabilization

• Patients with intracerebral hemorrhage (ICH) must be treated as a medical emergency with immediate evaluation by physicians with expertise in hyperacute stroke management, as recommended by the American Heart Association 1, 2
• Rapid initial evaluation of airway, breathing, and circulation (ABCs) should be performed immediately upon arrival, according to the American College of Emergency Physicians 3, 4
• Neurological examination should be conducted to determine focal deficits and assess stroke severity using standardized scales, such as the National Institutes of Health Stroke Scale (NIHSS) for awake or drowsy patients, as recommended by the National Institute of Neurological Disorders and Stroke 1, 3
• Immediate neuroimaging with CT or MRI is mandatory to confirm diagnosis, location, and extent of hemorrhage, as recommended by the American College of Radiology 1, 4

Diagnostic Workup

• Urgent blood work should include complete blood count, coagulation status (INR, aPTT), and random glucose, as recommended by the American College of Physicians 3, 5
• Evaluation should include questions about anticoagulant therapy and medication history, as recommended by the American Heart Association 1, 5
• In patients with confirmed acute ICH, vascular imaging (CT angiography, MR angiography, or catheter angiography) is recommended to exclude underlying lesions such as aneurysms or arteriovenous malformations, as recommended by the American Stroke Association 1, 6

Blood Pressure Management

• Blood pressure should be assessed on initial arrival to the ED and every 15 minutes until stabilized, as recommended by the American College of Emergency Physicians 1, 6
• For ICH patients presenting with systolic blood pressure between 150 and 220 mm Hg without contraindications to acute BP treatment, acute lowering of systolic BP to 140 mm Hg is safe and can improve functional outcomes, as recommended by the American Heart Association 5

Management of Coagulopathy

• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, as recommended by the American College of Physicians 5
• Patients whose INR is elevated due to vitamin K antagonists should have their medication withheld, receive therapy to replace vitamin K-dependent factors, correct the INR, and receive intravenous vitamin K, as recommended by the American College of Chest Physicians 5

Seizure Management

• New onset seizures occurring immediately before or within 24 hours of stroke onset should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited, as recommended by the American Academy of Neurology 3, 5
• A single, self-limiting seizure occurring at onset or within 24 hours should not be treated with long-term anticonvulsant medications, as recommended by the American Academy of Neurology 3

Monitoring and Nursing Care

• Initial monitoring and management should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise, as recommended by the American Association of Neuroscience Nurses 5
• A validated neurological scale should be conducted at baseline and repeated at least hourly for the first 24 hours, depending on patient stability, as recommended by the American Heart Association 1, 7

Surgical Considerations

• 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, as recommended by the American Association of Neurological Surgeons 5
• Neurosurgical consultation should be obtained promptly for evaluation of potential surgical interventions, as recommended by the American College of Surgeons 2, 7

Prevention of Complications

• Patients should have intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission, as recommended by the American College of Chest Physicians 5
• A formal screening procedure for dysphagia should be performed before initiating oral intake to reduce the risk of pneumonia, as recommended by the American Speech-Language-Hearing Association 5

Pitfalls and Caveats

• Early deterioration is common in the first few hours after ICH onset, with over 20% of patients experiencing a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation, as reported by the American Heart Association 7, 4
• Hematoma expansion occurs in 30-40% of patients and is a predictor of poor outcome; risk factors include presence of contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume, as reported by the International Journal of Stroke 1
• Diagnostic tests should not delay imaging or treatment decisions, as recommended by the American College of Emergency Physicians 3
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management, as recommended by the American Heart Association 1, 6

Management of Hemorrhagic Stroke

Blood Pressure Management

• Avoid antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 8

Fluid Management

• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 8
• Mild restriction of fluids is recommended to help manage brain edema 8

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to help venous drainage 8
• Treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 8
• Consider osmotherapy and hyperventilation for patients whose condition is deteriorating secondary to increased intracranial pressure 8
• Surgical interventions, including drainage of cerebrospinal fluid, can be used to treat increased intracranial pressure secondary to hydrocephalus 8

Seizure Management

• Recurrent seizures should be treated as with any other acute neurological condition 8
• Prophylactic administration of anticonvulsants to patients who have had stroke but not seizures is not recommended 8

Surgical Considerations

• Surgical decompression and evacuation of large cerebellar infarctions leading to brain stem compression and hydrocephalus is recommended 8
• Early surgery should be considered for patients with a Glasgow Coma Scale score 9–12 9

Prevention of Complications

• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 10
• Consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 10
• Do not use graduated compression stockings as they are less effective than intermittent pneumatic compression for VTE prevention 10

Monitoring and Care Setting

• Corticosteroids are not recommended for the management of cerebral edema and increased intracranial pressure following stroke 8

Management of Hemorrhagic Stroke

Blood Pressure Management

• The American Heart Association recommends avoiding antihypertensive agents that induce cerebral vasodilation, such as sodium nitroprusside, in patients with markedly elevated intracranial pressure 11
• Nicardipine is superior to labetalol for achieving and maintaining goal blood pressure, with a faster response time and fewer treatment failures, according to the American Heart Association guidelines 11

Management of Increased Intracranial Pressure

• The American Heart Association recommends considering osmotherapy, such as mannitol 0.25-0.5 g/kg IV over 20 minutes, every 6 hours, maximum 2 g/kg, for patients whose condition is deteriorating due to increased intracranial pressure 12
• Hyperventilation can be used as a temporizing measure for patients with herniation syndromes, as recommended by the American Heart Association 12
• Corticosteroids are not recommended for management of cerebral edema and increased intracranial pressure, according to the American Heart Association guidelines 12

Seizure Management

• Recurrent seizures should be treated as with any other acute neurological condition, according to the American Heart Association guidelines 12

Management of Hemorrhagic Stroke

Introduction to Guideline Recommendations

• The American Academy of Neurology recommends external ventricular drainage with intraventricular fibrinolysis for intraventricular hemorrhage, which promotes hematoma clearance, decreases mortality, and improves good functional outcomes 13

Monitoring and Care Setting

• The American Heart Association recommends maintaining a nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable, for initial monitoring and management in an intensive care unit or dedicated stroke unit 14