Hemorrhagic Stroke

Goals

  • Initial goals of treatment include preventing hemorrhage extension
  • Prevent and management of elevated intracranial pressure
  • Prevent other neurologic and medical complications.

Airway, Breathing, Circulation

  • Decreased resp drive in hemorrhage, vertebrobasilar ischemia, bihemispheric ischemia
  • Hypoventilation => vasodilation => Increased ICP
  • Maintain sats > 94% if hypoxic

Admission

  • To ICU unit

H&P

  • Establish time
  • NIHSS scores (>= 20 indicate severe stroke

Vitals

  • Fever
    • Contributes to brain injury, increased mortality
    • Differential
      • Meningitis
      • Subdural Empyema
      • Brain Abscess
      • Infective Endocarditis

Labs

  • Noncontrast head CT
  • Serum glucose/POCT glucose
  • O2 sat
  • ECG
  • CBC
  • Troponin
  • BMP
  • Coags
  • Consider
    • LFTs
    • Tox screen
    • Blood ETOH
    • Pregnancy test
    • ABG
    • CXR (consider aspiration)
    • LP if subarachnoid suspected
    • EEG if seizures suspected
    • Thrombin time or ecarin clotting time if patient taking direct thrombin inhibitor/direct factor Xa inhibitor
    • Type and cross in case FFP needed to reverse coagulopathy for ICH

Nursing/Monitoring

  • Cardiac monitoring for at least 24 hours to monitor for afib, longer monitoring = more chance to detect afib
  • IVF for dehydration
  • Patient Positioning
    • Ischemic stroke: Supine position 24 hours to increase cerebral perfusion (if tolerated)
    • Hemorrhagic, clinical deterioration > 24h, large infarction, or inc. ICP: HOB 30 degrees
  • Activity
    • Early mobilization (within 24h) reduces 3 month outcomes
  • Reduce Fevers (APAP for normothermia)

ICP

  • Elevate HOB to 30 degrees once hypovolemic is excluded
  • Analgesia and sedation, particularly in unstable, intubated patients
  • Normal saline initially should be used for maintenance and replacement fluids; hypotonic fluids are contraindicated. Mild hypernatremia should be tolerated.
  • Glucocorticoids should NOT be used to lower the ICP in most patients with ICH. A randomized trial found that dexamethasone did not improve outcome but did increase complication rates, primarily infection
  • Consider measurement of ICP
    • Invasive monitoring and treatment of ICP should be considered for patients with GCS <8
    • those with clinical evidence of transtentorial herniation
    • or those with significant IVH or hydrocephalus
  • Goal
    • maintaining a cerebral perfusion pressure (CPP) of 50 to 70 mmHg
  • Treatment
    • Mannitol bolus 1g/kg followed by infusions of 0.25 to 0.5 g/kg every 6 hours
      • goal plasma osmolality 300 to 310 msom/kg
    • Barbiturate if mannitol fails (decreases cerebral blood flow)
      • may cause hypotension
      • consider cont EEG monitoring
      • Dose titrated to a burst-suppression pattern of electrical activity
    • Hyperventilation
      • Goal PaCO2 of 25 to 30 mmHg
      • Dramatic lowering of ICP, but only lasts minutes to hours
      • Reserve for when other therapies have failed
    • Neuromuscular Blockade
      • Inc risk of pneumonia and sepsis
      • No way to do neuro eval
    • Ventriculostomy for obstructive hydrocephalus
      • Common complications of thalamic hemorrhage with third ventricule compression and of cerebellar hemorrhage with fourth ventricle compression
      • Frequently used in the setting of intraventricular hemorrhage with hydrocephalus

Surgery

  • Indications for decompression
    • Cerebellar Hemorrhage
      • cerebellar hemorrhages greater than 3 cm in diameter who are deteriorating
      • patients with brainstem compression
      • hydrocephalus due to ventricular obstruction
    • Supratentorial hemorrhage
      • Controversial
      • Reserved for life-threatening mass effect
    • Intraventricular Hemorrhage
      • At risk for hydrocephalus especially if 3rd and 4th ventricles are involved
      • If neurological deterioration, get emergent CT scan
      • Consider ventriculostomy and external ventricular drainage

Hemostatic therapy

  • do not use unless to reverse warfarin
  • vitamin k
  • recombinant factor VIIa

Procedures

  • Echocardiogram
  • NPO until swallow eval

Glucose Control

  • Hyperglycemia is associated with worsening outcomes
  • treatment for hyperglycemia to achieve serum glucose concentrations in the range of 140 to 180 mg/dL

Blood Pressure Control

  • For patients with SBP >200 mmHg or MAP >150 mmHg
    • consider aggressive reduction of blood pressure with continuous intravenous infusion of medication accompanied by frequent (every five minutes) blood pressure monitoring
  • For patients with SBP >180 mmHg or MAP >130 mmHg and evidence or suspicion of elevated ICP
    • consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous medication to keep cerebral perfusion pressure in the range of 61 to 80 mmHg
  • For patients with SBP >180 mmHg or MAP >130 mmHg and no evidence or suspicion of elevated ICP
    • consider a modest reduction of blood pressure (eg, target MAP of 110 mmHg or target blood pressure of 160/90 mmHg) using intermittent or continuous intravenous medication, and clinically reexamine the patient every 15 minutes

Lytics

  • Alteplase for treatment of acute ischemic stroke within 3 hours

Reversal of anticoagulation

  • Warfarin => vit K
  • Heparin => Protamine sulfate

Seizure

  • Epidemiology
    • The reported risk of seizures in patients with acute spontaneous ICH ranges from 4.2 to 29 percent
    • Seizures are more common in lobar as compared to deep hemorrhage
    • The frequency depends in part on the extent of monitoring, as seizures associated with ICH are often nonconvulsive
  • PPX
    • 2010 guidelines recommend against ppx use of AEDs
  • Treatment
    • Individualized treatment
    • Current guidelines suggest IV fosphenytoin or phenytoin

Meds

  • Antipyretics for fever
  • Insulin for hyperglycemia (target 140-180)
  • SCDs, no AC
  • Normal saline used for maintenance and replacement fluids, no hypotonic fluids
  • NPO until swallowing evaluated
  • GCS < 8, intubate
  • Antithrombotic therapy initiated within 48hours of stroke onset
  • PPX for DVT
  • Antithrombotic therapy at discharge
  • Lipid lowering therapy
  • Smoking cessation

Prognosis

  • Prognostication is uncertain, current guidelines suggest aggressive care for 24 hours after ICH onset and postponement of DNR orders during that time

 

 

The Mandatory Disclaimer: All information on this website is purely for educational and training purposes. Use best clinical judgement, the most current reference articles, medical standards of care, and specialist consultations when making clinical decisions for your patients.

Last Updated August 27, 2015