Hemorrhagic stroke resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Overview

Hemorrhagic stroke is defined as rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma. It is important to note that only non-traumatic causes of CNS hemorrhages are classified as stroke. Hemorrhagic stroke consists of:

  • Intracerebral Hemorrhage (ICH)

This is defined as a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma. Therefore, it consists of: 1. Intraparenchymal hemorrhage 2. Intraventricular hemorrhage 3. Parenchymal hemorrhages following CNS infarction[1]

Type I - confluent hemorrhage limited to ≤30% of the infarcted area with only mild space-occupying effect.
Type II - >30% of the infarcted area and/or exerts a significant space-occupying effect.
  • Subarachnoid Hemorrhage (SAH)

This is defined as bleeding into the subarachnoid space (the space between the arachnoid membrane and the pia mater of the brain or spinal cord). This consists of: 1. Aneurysmal SAH 2. Non-aneurysmal SAH

Time of Onset

Time of onset is defined as when the patient was last awake and symptom-free or known to be “normal".[2]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

  • All the causes of stroke are life-threatening.

Common Causes

Management

Intracerebral Hemorrhage

Diagnosis

 
 
 
 
 
❑ Check vitals
❑ Stabilize ABC
❑ Brief Hx
❑ Rapid physical exam -neuro exam, NIHSS
❑ Activate stroke team
❑ Stat fingerstick
❑ Basic labs, troponin, EKG
❑ NPO
❑ Obtain stroke protocol
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-contrast CT (or MRI)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
Negative
 
Ischemic Stroke
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intracerebral Hemorrhage
 
Subarachnoid Hemorrhage
 
Strong Suspicion for SAH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Management of ICH
 
 
 
 
 
 
May consider lumber puncture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Management of SAH
 
Xanthochromia or bloody CSF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
No SAH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Strong Suspicion for SAH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Traumatic tap?
Poor Technique?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ CTA/MRA
❑ Consult to Neurosurgeon
❑ Talk with superior
 
Normal CSF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Obtain more Hx and Investigation
❑ Rule out other causes
❑ Analgesia
 
 
 


 
 
 
 
 
 
 
 
 
 
 
Hx & PE suggestive of hemorrhage
Stabilize ABC
Assess GCS
CT confirmed CNS bleed
Consult to ICU, Neurosurgery
CBC, BMP, PT/PTT/INR/Fibrinogen, Type & CM
NPO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical Management
 
 
 
 
 
 
 
 
 
Surgical Management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Coagulopathy
 
BP Control
 
Elevated ICP
 
Hydrocephalus
IVH
 
Cerebellar Hemorrhage
 
Lobar Hematoma (clots) >30mls
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If >3cm
or
Any size with neurological deterioration
or
Brainstem compression and/or
hydrocephalus from ventricular obstruction
 
If >1cm and accessible
(within 1cm from surface)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ventricular drainage
 
May Consider Surgical Evacuation
 
May Consider Craniotomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Supportive Care
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nurse in NICU, IVF - N/S
Manage Hyperglycemia with Insulin (aim between 80-110 mg/dL)
Temp <37.5 deg C
BP Control <140/90
DVT Prophylaxis - Intermittent pneumatic compression + elastic stockings
Seizure Control - IV Fosphenytoin or phenytoin
Loading dose - 10-20mg PE/Kg slowly over 30 mins (max 150mg PE/min
Maintenance dose - 4-6mg PE/Kg/day in divided doses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



Coagulopathy

 
 
 
 
 
 
Consult to Hematologist
for specific dosing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Coagulation factor deficiency
 
Severe Thrombocytopenia
 
Elevated INR due to OACs
 
 
TPA-Induced Parenchymal Hemorrhage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer deficient factors
 
Platelet transfusion
(titrate according to follow-up labs)
 
 
 
 
 
 
 
TPA Reversal
Administer Cryoprecipitate (1-2 U/10 Kg)
Plus
Platelet transfusion (titrate according to follow-up labs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Warfarin
 
Heparin
 
Argatroban
No antidote available
You may consider
Desmopressin acetate - 0.3 mcg/kg, plasma concentrates, rFVIIa, dialysis
 
Consult to Neurosurgery
Consider repeat CT to assess hemorrhage size
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D/C Warfarin
Administer FFP - 10-15 ml/kg
+
IV vitamin K - 10 mg slowly
Prothrombin Complex Concentrate
(reasonable alternative to FFP) - 15-50 U/Kg
 
IV Protamine sulfate
UFH
1 mg/100 units → 30 mins since UFH was D/C
0.5-0.75 mg/100 units→30-60 mins
0.375-0.5 mg/100 units→60-120 mins
0.25-0.375 mg/100 units→ >120 mins
Infuse slowly, not >5 mg/min

LMWH
Administer 1 mg for each mg of LMWH administered in the last 4-8 hours
 


Blood Pressure

 
 
Blood Pressure Management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SBP >200 mmHg
or
MAP >150 mmHg
 
SBP >180 mmHg
or
MAP >130 mmHg
 
 
 
 
 
 
 
 
 
 
 
Monitor BP every 5 mins
Continuous IV antihypertensive infusion
 
Evidence/Suspicion of Elevated ICP
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
ICP Monitoring
Maintain CPP ≥60 mmHg
Intermittent or Continuous
 
Intermittent/Continuous Infusion
Aim at MAP of 110 mmHg or BP of 160/90 mmHg
Check vitals every 15 mins



Elevated Intracranial Pressure

 
 
Elevated ICP >20-25 mmHg
 
 
 
 
 
 
 
 
 
Indications for Treatment
GCS < 8
Clinical evidence of transtentorial herniation
Significant IVH or hydrocephalus
 
 
 
 
 
 
 
 
 
 
Eligible
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
Aggressive Measures
 
General Measures
 
 
 
 
 
 
General Measures
Elevate head of bed 30 degrees
Pain Control - IV morphine or alfentanil
Light Sedation - IV propofol
 
 
 
 
 
 
Insert ICP monitor and maintain CPP of 50-70 mmHg
 
 
 
 
 
 
ICP still >20-25 mmHg
First line
Ventricular Drainage; if fails

2nd Line
IV mannitol bolus - 0.25-1.0 g/kg
or
Hypertonic saline (23.4% 30cc) bolus; if fails

3rd Line
Sedation
Neuromuscular Blockade
Mild Hyperventilation (PaCO2 30-35 mmHg); if fails

4th Line
Hypothermia, hemicraniectomy, barbiturate coma
 
 
 
 
 
Follow-up CT scan after every stage
 
 

All algorithms are based on recommendations from AHA/ASA for the management of spontaneous intracerebral hemorrhage (2010)[3]

Dos

  • Acute lowering of blood pressure to a systolic BP of 140 mmHg is safe and recommended for SBP between 150 and 220 mmHg.

Don'ts

  • No place for prophylactic anti-convulsants.
  • Recombinant FVIIa is not recommended for the treatment of coagulopathy in intracranial hemorrhage.

References

  1. Trouillas, P.; von Kummer, R. (2006). "Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke". Stroke. 37 (2): 556–61. doi:10.1161/01.STR.0000196942.84707.71. PMID 16397182. Unknown parameter |month= ignored (help)
  2. Jauch, EC.; Saver, JL.; Adams, HP.; Bruno, A.; Connors, JJ.; Demaerschalk, BM.; Khatri, P.; McMullan, PW.; Qureshi, AI. (2013). "Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (3): 870–947. doi:10.1161/STR.0b013e318284056a. PMID 23370205. Unknown parameter |month= ignored (help)
  3. Morgenstern, LB.; Hemphill, JC.; Anderson, C.; Becker, K.; Broderick, JP.; Connolly, ES.; Greenberg, SM.; Huang, JN.; MacDonald, RL. (2010). "Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 41 (9): 2108–29. doi:10.1161/STR.0b013e3181ec611b. PMID 20651276. Unknown parameter |month= ignored (help)

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