eMedicine Specialties > Emergency Medicine > Neurology

Stroke, Hemorrhagic: Treatment & Medication

Author: Denise Nassisi, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center
Contributor Information and Disclosures

Updated: Feb 5, 2008

Treatment

Prehospital Care

  • Identify and address, as clinically indicated, any compromise of ABCs.
  • Recognize signs and symptoms of stroke.
  • Notify the receiving hospital.
  • Rapid transport to the closest facility capable of providing appropriate stroke care (if applicable).
  • In general, do not treat elevations of blood pressure (BP) in the field.

Emergency Department Care

  • Assess ABCs. Address any compromise in patient's status as clinically indicated.
  • Establish intravenous (IV) access.
  • Obtain bedside glucose determination.
    • Hypoglycemia may mimic stroke.
    • Hyperglycemia has been associated with poorer outcomes in stroke patients.
  • Institute cardiac monitoring and obtain an ECG.
  • The role of prophylactic anticonvulsant therapy has not been clearly defined. A brief period of anticonvulsant therapy soon after hemorrhagic stroke onset may reduce the risk of early seizures in patients with lobar hemorrhage. Phenytoin in conventional doses is commonly used.
  • Careful blood pressure (BP) monitoring is important.
    • No controlled studies define optimum BP levels.
    • Greatly elevated BP is thought to lead to rebleeding and hematoma expansion.
    • Patients who have had a stroke may lose their cerebral autoregulation of cerebral perfusion pressure.
    • Although BP elevations may risk further hemorrhage, too rapid or aggressive BP lowering may compromise cerebral perfusion.
    • The American Heart Association guidelines for treating elevated BP are as follows:
      • (1) If systolic BP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of BP with continuous intravenous infusion with frequent BP (q5min) checks.
      • (2) If systolic BP is >180 mm Hg or MAP is >130 mm Hg and there is evidence or suspicion of elevated ICP, then consider monitoring of ICP and reducing blood pressure using intermittent or continuous intravenous medications to maintain cerebral perfusion pressure >60-80 mm Hg.
      • 3) If systolic BP is >180 or MAP is >130 mm Hg and there is NOT evidence or suspicion of elevated ICP, then consider modest reduction of BP (target MAP of 110 mm Hg or target BP of 160/90 mm Hg) with BP checks every 15 minutes.
  • Intubation should be performed for patients who demonstrate potential loss of airway protective mechanisms or signs of brainstem dysfunction. If intubation is needed, rapid sequence intubation should be performed with technique and medications aimed at limiting any increase in intracranial pressure.
  • Currently, no effective targeted therapy for hemorrhagic stroke exists. Much interest has been generated to determine if treatment with hemostatic therapy may be effective. A preliminary study of treatment with recombinant factor VIIa demonstrated reduced mortality and improved functional outcomes. However, unfortunately, the results of the larger randomized trial revealed no overall benefit of treatment. Further studies are necessary to develop other potential treatment options.
  • Patients on warfarin with elevated international normalized ratio (INR) must be treated to lower the INR to prevent hematoma expansion. Treatment options include vitamin K and administration of clotting factors, including fresh frozen plasma (FFP), prothrombin complex concentrates (PCC), and recombinant factor VIIa.

Consultations

  • Emergent neurosurgical or neurological consultation often is indicated; local referral patterns may vary.
    • A potential treatment of hemorrhagic stroke is surgical evacuation of the hematoma. The role of surgical treatment for supratentorial intracranial hemorrhage remains controversial. Outcomes in published studies are conflicting. A published meta-analysis of studies suggested some promise for early surgical intervention. However, a recent study comparing early surgery versus initial conservative treatment failed to demonstrate a benefit with surgery.
    • Surgical intervention for cerebellar hematoma has been shown to improve outcome. It can be lifesaving in the prevention of brainstem compression.
    • Need for invasive intracranial pressure monitoring should be assessed by the neurosurgeon.
    • Need for emergent cerebral angiography should be assessed by the neurosurgeon. Patients with no clear cause of the hemorrhage and who would otherwise be candidates for surgery should be considered for angiographic evaluation.

More on Stroke, Hemorrhagic

Overview: Stroke, Hemorrhagic
Differential Diagnoses & Workup: Stroke, Hemorrhagic
Treatment & Medication: Stroke, Hemorrhagic
Follow-up: Stroke, Hemorrhagic
Multimedia: Stroke, Hemorrhagic
References
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References

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Further Reading

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Keywords

intracerebral hemorrhage, ICH, intracerebral bleeds, hypertension, neurologic function, cerebrovascular accident, CVA, stroke syndrome, thrombosis, embolism, hemorrhage, hemorrhagic stroke, cerebrovascular disease, neurologic complications, antithrombotic therapy, thrombolytic therapy, focal neurologic deficits, bleeding diatheses, iatrogenic anticoagulation, coagulopathies, anticoagulant therapy, iatrogenic hemorrhagic stroke, cerebral amyloidosis, cocaine abuse, mass effect of hematoma, hemiparesis, quadriparesis, hemisensory loss, aphasia, hemi-inattention, brainstem compression, brainstem herniation, apnea, limb ataxia, diplopia, nystagmus, oropharyngeal weakness, dysphagia, crossed signs, new-onset seizure, stroke, stroke management

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Contributor Information and Disclosures

Author

Denise Nassisi, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center
Denise Nassisi, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Heart Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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