Management of Acute Hemorrhagic Stroke

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Spontaneous, nontraumatic intracerebral hemorrhage (ICH) remains a significant cause of morbidity and mortality throughout the world. However, population-based studies indicate that most ICHs in most patients are survivable with good medical care thus emphasizing the importance of improved  clinical care in determining ICH outcome.  

Clinical presentation 

  • Severe headache, vomiting,
  • Focal neurological deficits
  • Decreased level of consciousness that may progress to coma
  • Symptom progression over minutes of hour

Investigations 

  • Rapid neuroimaging: plain CT to distinguish ischemic stroke from ICH
  • MRI  with  angiography-useful  to  evaluate  for  underlying  structural  lesions  e.g.,  vascular malformations and tumors in suspicious cases

Admit  all  patients  with  ICH  in  an  ICU or  dedicated  stroke  unit  for  initial  management  and  monitoring. 

Pharmacological Treatment 

For  elevated  SBP  (150-220mmHg),  initiate  BP  lowering  treatment,  target  at  140mmHg.  Consider  more aggressive reduction if SBP>220mmHg. 

C: labetalol (IV) at 1mg/min until target SBP is attained. 

Anticoagulation-related ICH: withhold anticoagulants and correct INR, if elevated, start on vitamin K  and consider FFP transfusion 

B: phytomenadione (vitamin K) (IV) 1mg slow infusion over 60 minutes 

If increased ICP based on clinic radiological features, give 

C: mannitol (IV bolus) 0.25-1gm/kg 4-6hourly for 24-72hours 

OR 

C: hypertonic saline 3% (IV bolus) at 3-5ml/kg 4-6hourly for 24-72hours 

Monitor  serum  osmolarity  and  renal  function  when  giving  Mannitol  or  Hypertonic  saline,  stop  if  osmolarity goes >320mOsm/L 

Treat fever with antipyretic medications and/or external cooling methods 

D: paracetamol (IV) 1g 8hourly for 3-5days then when required 

Perform  regular  monitoring  and  control  of  blood  glucose  to  prevent  both  hyperglycemia  and  hypoglycemia. 

Treat clinical or electrographic seizures associated with decreased loss of consciousness    

S: levetiracetam (PO/IV) 500mg 12hourly for 2weeks 

C: phenytoin (IV) 15mg/kg loading dose over 30min, then maintenance at 100mg 8hourly  for 2weeks. 

Non-pharmacological Treatment 

  • Apply  compressive  stockings  or  intermittent  pneumatic  compression  at  admission  to prevent VTE
  • LMWH can be started later after cessation of bleeding in immobile patients.
  • Consider  systemic  anticoagulation  or  IVC  filter  only  in  patients  with  symptomatic  deep vein thrombosis or Pulmonary embolism.

Surgical management 

  • Consider neurosurgical evaluation for  External  Ventricular  drainage  (EVD)  in patients with  decreased  level  of  consciousness  from  resultant  hydrocephalus  in  the  setting  of  intraventricular hemorrhage. 
  • Refer  for  surgical  evacuation  of  hematoma  as  soon  as  possible  in  patients  with  cerebellar  hemorrhage  who  are  deteriorating  neurologically  or  who  have  brainstem  compression and/or hydrocephalus from ventricular obstruction  
  • For  supratentorial  hematomas,  consider  evacuation  in  deteriorating  patients  with  or  without decompressive craniectomy as a life-saving measure in selected cases, based on  expert neurosurgical clinical judgement. 
  • Consider minimally invasive clot evacuation via stereotactic or endoscopic aspiration with  or without thrombolytic usage, based on expert clinical judgement and available resources.