Hemorrhagic Stroke Treatment GUIDELINES

At least 30 % patients with hemorrhagic stroke / intra cerebral hemorrhage die before reaching a hospital or without receiving adequate hospital care. Its a medical emergency and needs to be treated promptly for better outcome. Most if not all of the points mentioned below are for residents on duty in the ER taking care of patients day in and day out. Usually in emergency duties there are 3 to 4 critical patients that need to be identified and given utmost priority. Hemorrhagic stroke is certainly one of those cases. Even though the prognosis is bleak and unpredictable in most cases, all bases must be covered scientifically to ensure optimum chances of recovery.

Presentation can vary depending upon the specific brain region that is involved. It could be sudden loss of consciousness, seizures, altered mental state, nausea and vomiting, vertigo, visual loss, aphasia or focal neurological deficits.
Drug history is important especially in relation to anti platelets like aspirin/ clopidogrel / dipyridamole or anticoagulants like warfarin/ heparin / enoxaparin/ rivaroxaban etc. These medications should be pointed out specifically and stopped immediately.
Patient should be stabilized. ABC , Airway Breathing Circulation should be assessed and basic life support should be provided.
Vitals should be recorded including blood pressure, pulse and temperature. Blood glucose should also be measured immediately via glucometer.
GCS score should be calculated to provide a rough guideline for further management based on severity.
There is no reliable way to differ between ischemic and hemorrhagic stroke based upon presentation alone. CT brain should be done to rule out a bleed. It is important to assess the presence of cerebral edema usually referred to as a tense brain with squashed / compressed ventricles. Ventricular extension of the bleed should be assessed.
Fundoscopy should be done
Complete blood count – look for low platelets and a high TLC, Basic metabolic panel – look for any comorbid renal, liver dysfunction, hypoglycemia, hyperglycemia/ diabetes or electrolyte imbalance.
Bleeding and Clotting time plus PT/APTT testing should also be done especially with significant drug history as enumerated above
- On brain imaging look for intra ventricular hemorrhage, perilesional or cerebral edema or hydrocephalus or any mass effect/ shift of the ventricles.
- BLOOD PRESSURE : Usually a patient would present with a high blood pressure. There are no optimum BP levels for hemorrhagic stroke and case to case decisions are to be made. However, as general rule , say a patient presents with BP of 240/ 120 then it must be lowered actively to at least 180 systolic.
- Labetalol is a good option. In a hypertensive emergency labetaol is given 20 mg IV over 2 minutes initially and then 40 to 80 mg IV over the next 10 minutes based upon the response. BP should be monitored every 5 to 10 minutes during this active lowering phase. Total dose should not exceed 300 mg in this phase.
- An alternate is 1– 2 mg per minute by continuous IV infusion with total dose not exceeding 300 mg.
- Nitroprusside raises intracranial pressure and should be avoided.
- For definite BP control ACE inhibitors like captopril or enalapril should be added.
- A Question, Why not ARBs? Well, ARBs take much longer time to occupy the receptors and may take days to weeks for the antihypertensive effect to manifest. While ACE inhibitors lower BP immediately by acting on the enzyme directly. This is why captopril 25 mg sublingual is a good initial option if labetalol is not available.
- This acute lowering in blood pressure resulted in reduction in size of hematoma and halted progression on 24 hour repeat CT scans in a number of studies, thus contributing to overall reduction in mortality. (INTERACT 1 and 2 – Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial)
- Addition of nifedipine can be considered along with ACE inhibitors for definite control. Nicardipine and hydralazine are also use in refractory cases.
- To reduce the chances of a re bleed , the optimum reduction target should be 140 systolic over the long term.
- Though there is much confusion and debate among all the latest studies and guidelines, as a rule of thumb anti epileptics should be added especially in a large bleed and altered mental state, prophylactically as well as therapeutically. For acute attacks, valium and lorazepam can be given.
- Head end of the bed should be at 30°. This angle lowers intracranial pressure. The head should not be turned to the side.
- PPIs like omeprazole should be added.
- Fever should be lowered as a normal temperature is associated with lower mortality.
- Osmotic diuretic therapy with mannitol, while maintaining adequate cerebral perfusion pressure of greater than 70 mm Hg, should be employed in a large bleed with mass effect. It has to be given rapidly rather than a slow infusion for it to have any significant effect.
- Hyperventilation is generally not recommended now for lowering ICP as its transient and the rebound effect can be counterproductive.
- rFVIIa hemostatic trial has failed to demonstrate any benefit and is not considered a treatment option.
- Addition of Statins improves outcome.
- Steroids are controversial. They are usually given in large bleeds with perilesional edema and mass effect.
- Neurosurgical ( shunting) and endovascular consultations (in case of an aneurysm requiring cerebral angiography/ clipping ) should be kept in mind based on the specific presentation.
- Side nursing should be encouraged. Aspiration pneumonia should be looked for and prevented especially in neglected patients. NG and catheter should be passed. Antibiotic cover, if needed including anaerobic cover should be given especially in our setting.
- Endotracheal intubation should be considered in altered mental state, seizures, low GCS and respiratory distress/ dropping saturation
- ICU referral/ consultation should be sought.