Hemorrhagic stroke management

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AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015)

Management of ICH

AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)

Management of aSAH

AHA/ASA Guideline Recommendation for the Primary Prevention of Stroke (2014)

Primary Prevention of Stroke

AHA/ASA Guideline Recommendations for Prevention of Stroke in Women (2014)


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Pregnancy and Complications
Cerebral Venous Thrombosis
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Risk Factors Commoner in Women

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Hemorrhagic stroke management

Anticoagulants and antithrombotics, key in treating ischemic stroke, can make bleeding worse and cannot be used in intracerebral hemorrhage. Patients are monitored and their blood pressure, blood sugar, and oxygenation are kept at optimum levels.

Coagulation factor deficiency or platelet disorder treatments

Patients with a known coagulation factor deficiency or platelet disorder:[1][2]

  • Replacement of the appropriate factor or platelets
  • Hematology consult

patient undergoing an IV heparin infusion

  • Protamine sulfate IV injection at a dose of 1 mg per 100 U of heparin (maximum dose 50 mg) with adjustment based on time elapsed since discontinuation of heparin infusion

Patients who are receiving low-molecular-weight heparin (reversal may be incomplete)

  • Protamine sulfate IV injection at a dose of 1 mg per 100 U of heparin (maximum dose 50 mg)

Vitamin K antagonists (VKAs)

Rapid correction of the international normalized ratio (INR) is recommended.

Recently new treatments have emerged as potential therapies such as:[3][4]

  • Prothrombin complex concentrates (PCCs) contains factors II, IX, X, and VII. PCC does not require cross matching, can be reconstituted and administered rapidly in a small volume (20–40 mL) and Several studies have shown that PCCs rapidly normalize the INR (within minutes) in patients taking VKAs.
  • Activated PCC FEIBA (factor VIII inhibitor bypassing activity)
  • Recombinant activated factor VIIa (rFVIIa)

New Anticoagulant Medication–Related ICH

There are no randomized trials of reversing agents for newer anticoagulants among patients with ICH or other major bleeding complications. Currently available agents in the United States (dabigatran, rivaroxaban, and apixaban) have relatively short half-lives ranging from 5 to 15 hours. Evaluation of the activated partial thromboplastin time and prothrombin time and consultation with a hematologist are reasonable to individualize care. Potential reversal strategies using FEIBA, other PCCs, or rFVIIa might be considered.

  • Activated charcoal can be used if the most recent dose of dabigatran, apixaban, or rivaroxaban was taken within the previous couple of hours[5]
  • FFP is of unclear utility, and vitamin K is not useful
  • FEIBA or rFVIIa may be better for the direct thrombin inhibitor (dabigatran)
  • PCCs may be better for the factor Xa inhibitors (rivaroxaban and apixaban)[6][7]
  • Hemodialysis has been noted as an option for dabigatran, but less so for rivaroxaban or apixaban[8]

Antiplatelet Medication–Related ICH

Studies addressing the effect of prior antiplatelet agent use or platelet dysfunction on ICH growth and outcome have found conflicting results.[9][10][11][12]

Thromboprophylaxis in ICH Patients

Patients with ICH have a high risk of thromboembolic disease.[13]

  • Intermittent pneumatic compression begun as early as the day of hospital admission reduced the occurrence of proximal DVT[14]
  • ICH patients who develop DVT or PE may be considered for full systemic anticoagulation or placement of an inferior vena cava (IVC) filter[15]

BP-Lowering Treatment

  • Overall, current evidence indicates that early intensive BP lowering is safe and feasible in patients with intracerebral hemorrhage (ICH) and that surviving patients show modestly better functional recovery, with a favorable trend seen toward a reduction in the conventional clinical end point of death and major disability.
  • It is reasonable for intracerebral hemorrhage (ICH) patients to receive early treatment targeted to an SBP level <140 mmHg to improve their chances of achieving better functional recovery if they survive the condition.
  • There are fewer data available pertaining to the safety and effectiveness of treatment in patients with very high BP (sustained SBP >220 mm Hg) on presentation, large and more severe ICH, and those requiring surgical decompression.

Glucose management

A randomized trial showing improved outcomes with tight glucose control (range, 80–110 mg/dL) using insulin infusions in mainly surgical critical care patients. However, hypoglycemia should be avoided.[16]

Temperature managemen

Although many studies provide a rationale for treatment of fever in intacerebaral hemorrhage (ICH) patients, maintenance of normothermia has not been clearly demonstrated as beneficial to outcome.[17][18]

Antiseizure drugs

  • Prophylactic anticonvulsant medication has not been demonstrated to be beneficial.
  • Clinical seizures or electrographic seizures in patients with a change in mental status should be treated with antisezure drugs.
  • Continuous EEG monitoring should be considered in ICH patients with depressed mental status that is disproportionate to the degree of brain injury.

ICP Monitoring and Treatment

Because the usual causes of elevated ICP are hydrocephalus from IVH or mass effect from the hematoma (or surrounding edema), patients with small hematomas and limited IVH usually will not require treatment to lower ICP.

Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be consid- ered for ICP monitoring and treatment.

Corticosteroids should not be used, because they are not effective in ICH and increase complications

Intraventricular hemorrhage

2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage[24]

Hemostasis and Coagulopathy, Antiplatelet Agents, and DVT Prophylaxis: Recommendations

Patients with a severe coagulation factor deficiency or severe thrombocytopenia

Class I
"1.Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectivel (Level of Evidence: C)"

Patients with ICH whose INR is elevated because of VKA

Class I
"1.Patients with ICH whose INR is elevated because of VKA should have their VKA withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K (Level of Evidence: C)"
Class III (Harm)
"1.rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not recommended for VKA reversal in ICH (Level of Evidence: C)"
Class IIb
"1.PCCs may have fewer complications and correct the INR more rapidly than FFP and might be considered over FFP (Level of Evidence: B)"

Patients with ICH who are taking dabigatran, rivaroxaban, or apixaban

Class IIb
"1.For patients with ICH who are taking dabigatran, rivaroxaban, or apixaban, treatment with FEIBA, other PCCs, or rFVIIa might be considered on an individual basis. Activated charcoal might be used if the most recent dose of dabigatran, apixaban, or riva- roxaban was taken <2 hours earlier. Hemodialysis might be considered for dabigatran (Level of Evidence: C)"

Reverse heparin in patients with acute ICH

Class IIb
"1. Protamine sulfate may be considered to reverse heparin in patients with acute ICH (Level of Evidence: C)"

Patients with a history of anti platelet and ICH

Class IIb
"1.The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is uncertain (Level of Evidence: C)"

Hematoma expansion

Class III (Harm)
"1. Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus, rFVIIa is not recommended (Level of Evidence: A)"

prevention of venous thromboembolism

Class I
"1.Patients with ICH should have intermittent pneu- matic compression for prevention of venous throm- boembolism beginning the day of hospital admission (Level of Evidence: A)"
Class III (Harm)
"1.Graduated compression stockings are not beneficial to reduce DVT or improve outcome (Level of Evidence: A)"
Class IIb
"1.After documentation of cessation of bleeding, low- dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for pre- vention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset (Level of Evidence: B)"

ICH patients with symptom- atic DVT or PE

Class IIa
"1.Systemic anticoagulation or IVC filter placement is probably indicated in ICH patients with symptom- atic DVT or PE (Level of Evidence: C)"
"2. The decision between these 2 options should take into account several factors, including time from hem- orrhage onset, hematoma stability, cause of hemor- rhage, and overall patient condition (Level of Evidence: C)"

BP-Lowering: Recommendations

ICH patients presenting with SBP between 150 and 220 mmHg

Class I
"1.For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe (Level of Evidence: A)"
Class IIa
"1.For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg ) can be effective for improving functional outcome (Level of Evidence: C)"

ICH patients presenting with SBP >220 mmHg

Class IIb
"1. For ICH patients presenting with SBP >220 mm Hg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring (Level of Evidence: C)"

General Monitoring and Nursing Care: Recommendation

Class I
"1.Initial monitoring and management of ICH patients should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertis (Level of Evidence: B)"

Glucose Management: Recommendation

Class I
"1.Glucose should be monitored. Both hyperglycemia and hypoglycemia should be avoided (Level of Evidence: C)"

Temperature Management: Recommendation

Class IIb
"1.Treatment of fever after ICH may be reasonable (Level of Evidence: C)"

Seizures and Antiseizure Drugs: Recommendations

Class I
"1.Clinical seizures should be treated with antiseizure drugs (Level of Evidence: A)"
"2.Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiseizure drugs (Level of Evidence: C)"
Class III (Harm)
"1.Prophylactic antiseizure medication is not recommended (Level of Evidence: B)"
Class IIa
"1.Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status that is out of proportion to the degree of brain injury (Level of Evidence: C)"

Management of Medical Complications: Recommendations

Class I
"1.A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk of pneumonia (Level of Evidence: B)"
Class IIa
"1. Systematic screening for myocardial ischemia or infarction with electrocardiogram and cardiac enzyme testing after ICH is reasonable (Level of Evidence: C)"

ICP Monitoring and Treatment: Recommendations

Class III (Harm)
"1.Corticosteroids should not be administered for treatment of elevated ICP in ICH (Level of Evidence: B)"
Class IIa
"1.Ventricular drainage as treatment for hydrocephalus is reasonable, especially in patients with decreased level of consciousness (Level of Evidence: B)"
Class IIb
"1. Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A CPP of 50 to 70 mm Hg may be reasonable to maintain depending on the status of cerebral autoregulation (Level of Evidence: C)"

IVH: Recommendations

Class IIb
"1.Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncertain (Level of Evidence: B)"
"2.The efficacy of endoscopic treatment of IVH is uncertain (Level of Evidence: B)"


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