Managing hemorrhagic strokes

In this video, we look at the process to follow when managing a hemorrhagic stroke and what affects prognosis in these patients.

Gary R. Simonds, MD MHCDS FAANS
Gary R. Simonds, MD MHCDS FAANS
10th Sep 2021 • 4m read

When a patient presents with a hemorrhagic stroke, it can often be extremely complicated to manage. In this video, we look at the process to follow when managing a hemorrhagic stroke and what affects prognosis in these patients.

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Video transcript

In all patients presenting with sudden onset of severe neurological deficit, remember your ABCs. Be attentive to their airway, breathing, and circulation. Remember, intubation is often necessary, have a low threshold to intubate for compromised respiration and for coma. Resuscitate the patient as needed, you want them at least normovolemic.

Also always be mindful of the possibility of increased intracranial pressure and associated brain herniation. Run IV fluids at high maintenance rates. Absolutely avoid dehydration. You want the brain to be well perfused but avoid hypotonic IV fluids as they worsen cerebral edema. If hemorrhage has been defined, bring elevated blood pressure down to a systolic pressure of approximately 140 millimeters of mercury.

Labetalol and nicardipine are currently favorite antihypertensives for control of elevated blood pressure. Avoid over aggressive blood pressure reduction. Lowering elevated blood pressure to less than 140 milligrams of mercury may carry a worse outcome, that is higher rates of death and severe neurologic deficits. Elevate the patient's had a bed to 30 degrees, this will help lower intracranial pressure no matter the pathology.

As you are stabilizing the patient obtain a rapid history and neurological exam, look for major deficits. If the patient is in coma, evaluate the degree of coma. Vital Signs and neurological status must be continuously monitored. Obtain a complete blood count or CBC, metabolic panel, coagulation profile including prothrombin time and international normalized ratio and partial thromboplastin time, obtained cardiac troponins, obtain a pregnancy test in women of childbearing age, manage serum electrolytes, you're shooting for a sodium of over 140 mil equivalents per liter, and a serum osmolarity of over 300 millimoles per kilogram to help reduce brain swelling.

Use 3% sailne at 10 to 20 milliliters per hour to help raise serum sodium if necessary. Prepare to admit the patient to an ICU or stroke unit and notify neurology and or neurosurgery as they will want to be involved in the early management of the patient, particularly if there are signs of increased intracranial pressure. How should we manage the patient's medications? Well, we need to reverse anticoagulation and anti platelet medications in accordance with our pharmacists recommendations.

We'll also want to manage coagulopathies as effectively as possible. Ironically, 1 to 3 days after it has been established that there has been no re hemorrhaging, consider starting low molecular weight or unfractionated heparin as a prophylaxis against deep vein thrombosis and pulmonary embolism.

Note, it's a good idea to check with neurosurgery before doing this if your institution doesn't have a specific protocol for this situation. Recognize that there is an increased risk of seizures with lobar hemorrhages, that is hemorrhages in the periphery of the cerebral hemispheres. Seizures can certainly cloud clinical issues and cause rebleeding so for lobar hemorrhages, we tend to use levetiracetam 500 to 1000 milligrams twice a day as a prophylaxis against seizures, although frankly anticonvulsant use is not strongly supported in the literature.

Prophylactic anticonvulsant medications are not indicated in deep brain hemorrhages as seizures from such entities are unusual. Antionvulsant are also not recommended for post your fossa hemorrhage as the cerebellum does not seize. Steroids are generally not recommended for treating brain hemorrhages. However, they have occasionally been employed if there is significant associated brain edema.

In coma patients where aggressive management is desired, discuss with neurosurgery the use of an intracranial monitor or ventricular catheter to monitor intracranial pressure. Various therapeutic manipulations, and even surgery may be employed if intracranial pressure is dangerously elevated. In a previously stable patient, if there's deterioration in the neurological status, consider the following differential, re hemorrhage, the development of hydrocephalus, increased intracranial pressure, increased associated edema, seizures, or metabolic disturbances such as hyponatremia, uremia or hypocalcemia.

In a deteriorating patient, support and resuscitate the patient as needed, and obtain an emergent follow up noncontrast CT scan of the head. On the other hand, in patients who have stabilized and are recovering, initiate early aggressive rehabilitative therapy. Consider starting therapy 24 to 48 hours after it has been demonstrated that the patient has not sustained any re hemorrhage or after they have gone through surgery, the patient will often be dealing with significant neurological deficits.

Please recognize that many hemorrhagic strokes are devastating, resulting in death, coma, or profound neurological compromised. Thus, as we manage them, we should be mindful of the wishes of the patients and their families with respect to the aggressiveness of our care. Sadly, for many severe hemorrhagic strokes, surgery may offer no real hope of improvement. Therefore, expectant care, which means initiating no intervention to try to stave off death may be indicated in patients whose prognosis is particularly poor, with no real hope of profound improvement. Such patients may include the very elderly, those with poor premorbid conditions, those with large dominant hemisphere or deep brain or brainstem hemorrhages and those in deep coma.