Hemorrhagic stroke resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]
Definitions
Hemorrhagic Stroke
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:
- Intraparenchymal hemorrhage
- Intraventricular hemorrhage
- 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:
- Aneurysmal SAH
- 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
- Hypertension
- Bleeding disorders
- Illicit drug use (e.g., amphetamines or cocaine)
- Trauma
- Vascular malformations
- Rupture of arterial aneurysms
Management
Don't worry about the missing algorithm, its on sandbox vidit2
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
- ↑ 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) - ↑ 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) - ↑ 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)