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]


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]


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


Intracerebral Hemorrhage


❑ Check vitals
❑ Stabilize ABC
❑ Brief Hx
❑ Rapid physical exam -neuro exam, NIHSS
❑ Activate stroke team
❑ Stat fingerstick
❑ Basic labs, troponin, EKG
❑ Obtain stroke protocol
Non-contrast CT (or MRI)
Ischemic Stroke
Intracerebral Hemorrhage
Subarachnoid Hemorrhage
Strong Suspicion for SAH
Management of ICH
May consider lumber puncture
Management of SAH
Xanthochromia or bloody CSF
Strong Suspicion for SAH
Traumatic tap?
Poor Technique?
❑ 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
Medical Management
Surgical Management
BP Control
Elevated ICP
Cerebellar Hemorrhage
Lobar Hematoma (clots) >30mls
If >3cm
Any size with neurological deterioration
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


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)
Platelet transfusion (titrate according to follow-up labs)
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
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

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

Blood Pressure

Blood Pressure Management
SBP >200 mmHg
MAP >150 mmHg
SBP >180 mmHg
MAP >130 mmHg
Monitor BP every 5 mins
Continuous IV antihypertensive infusion
Evidence/Suspicion of Elevated ICP
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
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
Hypertonic saline (23.4% 30cc) bolus; if fails

3rd Line
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]


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


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


  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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