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

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".

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

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

Intracerebral Hemorrhage

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

Subarachnoid Hemorrhage

Suspicion of Aneurysmal SAH

Head CT

Intraparenchymal Hemorrhage Hydrocephalus Intraventricular Hemorrhage

NICU Management Stabilize ABC Brief Hx PE - GCS, Hunt-Hess Score, BP CBC, PT/PTT/INR, Type & CM, EKG IVF - N/S Consult to Neurosurgery D/C all antiplatelets Reverse all Anticoagulation DVT Prophylaxis - Pneumatic Compression Stockings Urgent meds Fosphenytoin 20 mg/kg IV bolus Analgesia - IV morphine Stool Softeners - docusate/senna PPI - Esomeprazole Oral Nimodipine - 60 mg 4 hourly Antipyretic IV Mannitol - 20% 1g/kg bolus if ↑ICP is suspected Assess for Tranexamic acid or Aminocaproic acid

Surgery

Large intraparenchymal Hge (>50 mLs) Middle Cerebral artery aneurysm

Age > 70 years Poor grade (WFNS IV/V) Aneurysm of Basilar Apex

Microsurgical Clipping

Endovascular Coiling

Delayed Follow-up vascular imaging Consider retreatment with coiling or clipping, if there is remnant

NICU Management

Manage Complications

Prevent

↑ICP Management NB - Avoid Hyperventilation

Symptomatic Vasospasm

HypoNa

Rebleeding

Vasospasm and delayed cerebral ischemia

Oral Nimodipine 60 mg 4 hourly Maintain Euvolemia - N/S or packed RBC transfusion in anemic paatients ↓ Induced HTN with phenylephrine, norepinephrine, dopamine ↓ Balloon angioplasty ↓ Intra-arterial vasodilators - nicardipine milrinone

Isotonic or Hypertonic saline (3%) Fludrocortisone acetate

BP control Maintain Euvolemia Tranexamic acid

Oral Nimodipine Maintain Euvolemia

Monitor

Neurostatus Vasospasm - daily TCD, CT/MR Perfusion imaging Seizures Volume status Strict glucose control Hyponatremia Heparin-induced thrombocytopenia - Platelet count/PT/PTT DVT

Dos

ICH

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

SAH

• Obtain a brief hx with emphasis on time of onset, h/o trauma, seizures, or cocaine use.
• Withold antihypertensives in severely impaired consciousness and in the absence of ICP measurement because the cerebral perfusion pressure must be maintained.

Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) minus Intracranial Pressure (ICP)

• Oral nimodipine should be administered to all patients with aneurysmal SAH.
• Strict maintenance of euvolemia and normal circulating volume to prevent delayed cerebral ischemia.

Don'ts

ICH

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

SAH

• No prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasms.
• Fenestration of the lamina terminalis should not be routinely performed to reduce the rate of shunt-dependent hydrocephalus.
• Long term use of anticonvulsants is discouraged except if the patient have a known risk factor for delayed seizure disorder: prior seizure, intracerebral hematoma, intractable hypertension, infarction, or aneurysm in the middle cerebral artery.
• Administering large volume of hypotonic fluids and intravascular volme contraction is not recommended after aneurysmal SAH.
• Avoid hyperventilation as a measure to reduce elevated ICP; it may worsen vasospasm.
• Avoid nitroprusside or nitroglycerin for blood pressure control; it may increase the cerebral blood volume.