Hemorrhagic Stroke (ICH)
I. What every physician needs to know.
Hemorrhagic stroke (due to intracerebral or subarachnoid hemorrhage) is the second most common cause of stroke. It is usually caused by the rupture of small arteries due to unrecognized or uncontrolled hypertension, but can be due to several other underlying etiologies discussed below.
II. Diagnostic Confirmation: Are you sure your patient has hemorrhagic stroke?
Hemorrhagic stroke (ICH) is diagnosed by the presence of blood in the intracerebral space in patients who present with signs and symptoms of stroke. These findings include hemiparesis, hemisensory loss, aphasia, ophthalmoplegia, and/or visual field deficits.
A. History Part I: Pattern Recognition:
Patients usually present with typical stroke-like symptoms (focal neurological deficits) such as complaints of loss of sensation of one side of the body (hemisensory loss), paralysis of one half of the body (hemiparesis), impairment of language (aphasia), inability to move eye balls due to paralysis of one of more of extraocular muscles (ophthalmoplegia), and/or loss of vision (visual field deficits).
Patients may also present with other complaints such as severe head ache, progressive worsening of mental status, neck stiffness and vomiting. These complaints are more common in patients with ICH, compared to ischemic stroke. These symptoms can vary depending on extent and severity of bleed.
Mostly neurological symptoms appear with exertion and get worse over a period of time. In certain cases, brain stem herniation from increased intracranial pressure may manifest as respiratory depression and myocardial arrhythmias.
B. History Part 2: Prevalence:
The annual incidence of ICH varies from 15-30 cases per 100,000. Intracerebral hemorrhages comprise 15% of all strokes (the rest being ischemic).
Smokers, alcoholics, elderly and diabetics are at higher risk of developing intracerebral bleeds. ICH is known to be more common in blacks compared to whites. Surprisingly, patients with low cholesterol levels (low LDL and TG) are also at higher risk of ICH.
Most common etiology of ICH is hypertension and its associated vasculopathy. Other factors which can also cause hemorrhagic stroke include vascular malformation (ruptured aneurysm) and amyloid angiopathy. Some less common causes include septic embolism (usually multiple hemorrhagic foci in the brain), underlying coagulopathy (such as anticoagulation with warfarin or thrombolysis), intracerebral tumor, vasculitis and drugs (cocaine, etc).
C. History Part 3: Competing diagnoses that can mimic hemorrhagic stroke.
Migraine, hypoglycemia, metabolic disorders (hypo or hypernatremia), seizure and post-ictal stage are the most important mimickers and can have similar presentations as ICH. A careful history, thorough physical examination and analysis of blood labs including blood glucose level and other metabolites can help with differentiating above mentioned diseases from ICH. Some of the psychiatric disorders can also present with signs and symptoms of stroke.
Ischemic stroke cannot be differentiated from ICH on the basis of history and physical examination. Non-contrast computed tomography (CT) scan of the brain is a quick and reliable test to differentiate between these two different entities.
D. Physical Examination Findings.
Physical signs depend on extent, severity and site of bleed.
In certain cases neck stiffness is the only presenting symptom that can be appreciated on physical examination.
In severe cases, physical exam findings can range from pin point pupils, unilateral facial palsy, opthalmoplegia, gaze palsy, loss of balance, dysarthria, deep coma, to hemiperisis hemisensory loss and complete motor paralysis.
Bilateral upgoing babinski sign is described more commonly in ICH compared to ischemic stroke.
E. What diagnostic tests should be performed?
Diagnosis of ICH is based on the combination of clinical exam and imaging studies. Although physical examination can help establish the diagnosis of stroke, there is no single physical exam finding or maneuver that can differentiate hemorrhagic from ischemic stroke.
1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
Once diagnosis of stroke is confirmed by history and physical examination, complete blood count (CBC), basic metabolic panel (BMP, including blood glucose level) and coagulation studies (including PT, PTT and INR) should be ordered before moving the patient to the CT scanner.
It includes evaluation of the platelet count, hematocrit and work up of any underlying bleeding disorder. With patients who present with alteration of consciousness, arterial blood gas (ABG) can help to evaluate underlying acid base disorder and blood Ph.
Catecholamines released from brain injury usually cause subendocardial ischemia which appears on EKG as ST segment changes, appearance of U waves or tall T waves and prolonged QT segment. Subendocardial ischemia can also be associated with mild elevation of cardiac biomarkers and should not be confused with simultaneous cardiac ischemia (such as Non ST Elevation Myocardial Infarction).
Other studies include complete metabolic panel (CMP), Hemoglobin A1C and fasting lipid panel, and can help evaluate underlying comorbidities of the patient. Toxicology screen can help with analyzing the cause of ICH.
2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
Non-contrast head CT is the best diagnostic test to diagnose ICH and is equivalent to magnetic resonance imaging (MRI). It can evaluate the size and extent of hematoma (involvement of ventricles) along with the presence or absence of midline shift or herniation of brain parenchyma. Only in patients with severe anemia, CT scan may not be ideal test to evaluate for ICH.
Typical sites of bleeding in hypertensive strokes are basal ganglia, brain stem and cerebellum. ICH from other causes can involve any part of brain. No further investigation is needed to evaluate the stroke in patients with severe uncontrolled hypertension with bleeding at the above mentioned areas.
In other cases, when clinical suspicions arise, magnetic resonance angiography (MRA) and magnetic resonance vengoraphy (MRV) can be obtained to evaluate the cause of hemorrhagic stroke. A repeat MRI (4 to 6 weeks after ICH) can also reveal underlying vascular malformation. Contrast enhanced MRI and CT angiography can also be used to evaluate the cause of ICH.
F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.
III. Default Management.
Management of ICH depends on the presenting condition. In most of the cases, patients need to be stabilized first (as discussed below). Once stabilized, further assessment (including history and physical examination), stat laboratory studies and CT scan should be ordered next to evaluate the etiology of stroke.
ICH is a medical emergency with a potential to expand in the first 6 hours. In some cases, intracerebral hematoma is known to expand for the first 24 hours. It is recommended to monitor these patients in the intensive care unit initially (specially during the first 24 hours) and patients' neurological status should be monitored closely.
In patients with severe hypertension, blood pressure control via intravenous antihypertensives and continuous blood pressure monitoring is recommended. Some experts recommend a target blood pressure of 160/90mm Hg, others advocate controlling the blood pressure to systolic blood pressure less than 140. Alternatively, mean arterial pressure (MAP) of 110mmHg and cerebral perfusion pressure at 60 to 80mmHg is also acceptable in patients with ICH.
Seizures are also common after ICH. In the recent past, experts recommended the prophylactic use of intravenous anti-epileptic medications in patients with ICH. The current guidelines advise against it and recommend use of anti-epileptic treatment only if a seizure occurs and not as prophylaxis. Phenytoin or fosphenytoin are the preferred medications in these cases.
Headache due to traction of nerves is at times associated with neck stiffness and requires appropriate analgesia and sedation (to improve agitation).
Other important points include treatment of fever, hyperglycemia (usually by intravenous insulin), elevated intracranial pressure and agitation, as these factors are known to be associated with worse outcomes. Simple measures like 30 degree elevation of the head of the bed are well known to improve intracranial pressure and decrease complications such as aspiration pneumonia.
The use of Factor VII treatment has not shown any benefit of survival during clinical trials.
In cases where ICH is due to warfarin toxicity, anticoagulation should be reversed with IV fresh frozen plasma (for immediate effect) and Vitamin K. Also, all antiplatelete medicines (such as aspirin and plavix) and anticoagulants should be immediately discontinued. It is important to know that IV vitamin K infusion can be associated with anaphylaxis and should be infused very slowly.
In patients with subarachnoid hemorrhage, nimodipine is known to decrease the risk of vasospasm. In patients where septic emboli are thought as a primary cause, emergent cardiac 2d Echo followed by cardiothoracic consult should be obtained. Broad spectrum antibiotics should be administered as soon as possible.
Surgery has not shown much benefit except in patients with greater than 3cm hematoma and rapid deterioration or brain stem compression, and/or hydrocephalus from ventricular obstruction.
Physical/occupational therapy and speech/swallow therapy consults should be obtained based on the patient’s deficits after stroke.
Other important points include aspiration precautions, management of good oral hygiene and evaluation for early removal of urinary catheter during hospital stay. Pneumonia and influenza vaccinations should be given before discharge from the hospital.
In patients with ICH, deep venous thrombosis prophylaxis (DVT) is very common and can be prevented by intermittent pneumatic compression devices. In severe cases, particularly in patients with hemiplegia, placement of inferior vena cava (IVC) filter and a low dose of heparin can be considered (use of heparin should be avoided for first four days after cessation of bleeding).
Physicians should also consider end of life discussion with the family and next of kin based on the patient’s condition and prognosis.
A. Immediate management.
Emergent management of ICH depends on the patient’s clinical status. In severe cases, protection of airway may precede diagnostic work-up. Immediate management steps are the same regardless of the etiology of stroke.
These include quick history and physical, airway screen and placing the patient on pulseoxymeter, cardiac monitor and oxygen, obtaining intravenous access and drawing essential blood labs. Once patient is stabilized, etiology of stroke should be established by non-contrast CT scan. After diagnosis is obtained (above mentioned) treatment should be initiated right away.
During initial assessment, physicians need to exclude mimickers such as seizures, post ictal status, migraine and hypoglycemia, as these are reversible causes and can present as stroke-like symptoms.
Blood pressure control should be obtained as soon as possible as it has shown to restrict the growth of hematoma.
Following these steps, management is dependent on the cause of ICH (please see default management for further treatment steps).
C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.
If coagulation abnormality is the underlying cause (such as warfarin overdose or ITP with rapidly dropping platelets), coagulation studies should be followed closely while respective blood products are replaced.
A CT scan should be repeated within the first 24 hours to see progression of the hematoma.
No other laboratory studies are required to monitor the response to, and adjustments in, management of acute stroke.
D. Long-term management.
Long-term management also depends on the neurological deficits of the stroke, these include long-term physical therapy, occupational therapy and speech therapy. Early ambulation and rehabilitation should be initiated in these patients.
In most of the cases where hypertension can be attributed to the cause of hypertensive stroke, no further investigation is indicated. Cases where cause of stroke cannot be due to hypertension (such as in patients with intracerberal bleeds in the non-typical areas, as described above) need further investigation.
In these cases, MRA and MRV can be obtained to evaluate the cause of hemorrhagic stroke. A repeat MRI (4 to 6 weeks after ICH) can also reveal underlying vascular malformation. Contrast enhanced MRI and CT angiography can also be used to evaluate the cause of ICH.
In cases with severe deficits, where patients cannot be extubated and are unable to feed themselves, the long-term plan should be discussed with the family including placement, tracheostomy and feeding tube (PEG) tube placement.
Long-term appropriate control of blood pressure is needed in these patients as part of a treatment plan as it has shown to decrease the recurrence rate of intracranial bleed.
At times surgical correction of arterial malformations may be planned to avoid re-bleeding.
E. Common Pitfalls and Side-Effects of Management
Glucocorticoids should not be used to lower the intracerebral pressure as it is not known to be associated with better outcomes. Intravenous nitroprusside used for the control of blood pressure can cause cyanide toxicity.
Intravenous labetalol should not be used in patients with congestive heart failure as it can exacerbate this condition.
Fever which persists for more than 24 hours is usually present in patients with ventricular extension of the ICH and is associated with poor outcome.
IV. Management with Co-Morbidities
A. Renal Insufficiency.
Nitroprusside, an intravenous antihypertensive is known to be associated with cyanide toxicity, especially in patients with renal insufficiency. Also, based on the cause of renal insufficiency, angiotensin converting enzyme inhibitors (ACEI) and diuretics may need to be avoided.
IV contrast can worsen renal failure.
B. Liver Insufficiency.
No change in standard management.
C. Systolic and Diastolic Heart Failure
Beta blockers should be avoided in patients with acute CHF. Use of other antihypertensives such as diuretics, ACEI and vasodilators may improve outcomes in this condition.
D. Coronary Artery Disease or Peripheral Vascular Disease
Use of antihypertensives such as ACEI, beta-blockers and intravenous nitroglycerin is better in these cases.
E. Diabetes or other Endocrine issues
Use of antihypertensives such as ACEI is better in diabetic patients. Aggressive control of blood sugar is recommended in diabetic patients with acute stroke.
No change in standard management.
G. Immunosuppression (HIV, chronic steroids, etc).
No change in standard management.
H. Primary Lung Disease (COPD, Asthma, ILD)
Beta-blockers should be avoided in patients as such medications can worsen bronchospasm.
I. Gastrointestinal or Nutrition Issues
No change in standard management.
J. Hematologic or Coagulation Issues
No change in standard management.
K. Dementia or Psychiatric Illness/Treatment
In cases of severe dementia, prognosis and treatment plan should be discussed in detail with the family.
No change in standard management in patients with psychiatric illness known.
V. Transitions of Care
A. Sign-out considerations While Hospitalized.
The on-call team should be signed out to obtain stat imaging study along with neurosurgery consult with any changes in the mental status of the patient. Detailed sign-out should be given regarding patients' current mental and neurological status. Team also should be given details about blood pressure control and overnight treatment strategy.
B. Anticipated Length of Stay.
Anticipated length of stay depends on case to case basis, generally patients with ICH without any superimposed complications stay in the hospital between 5-10 days.
C. When is the Patient Ready for Discharge.
Discharge should be planned in association with the recommendations from speech therapy, physical and occupational therapy. Patient’s home condition, place of discharge and availability of family support also effect the decision of their discharge. In mild cases, once patients are able to take care of themselves, discharge planning should be initiated.
In other cases (with severe residual outcomes) patients may be discharged to the nursing homes once long term plan is discussed with the family including placement of peg tube and tracheostomy.
D. Arranging for Clinic Follow-up
1. When should clinic follow up be arranged and with whom.
Patients should follow-up with the primary care doctor after discharge. Also follow-ups should be arranged with a neurologist. Outpatient’s physical/occupational therapy and speech therapy should also be arranged based on the patient’s residual deficits.
2. What tests should be conducted prior to discharge to enable best clinic first visit.
3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
E. Placement Considerations.
Based on the patient’s outcome following stroke, short or long-term placement in a skilled nursing facility may be required. Placement decision is usually based on recommendations from physical therapy/occupational therapy/speech and swallow evaluation and patient’s home support.
F. Prognosis and Patient Counseling.
Prognosis of ICH depends on extent and location of ICH. Patients who present with large ICH and stupor usually have worse outcomes. Also, the patient’s age and underlying medical conditions determines the final outcomes. Rapidity in change in size of the bleed and intraventricular extension are also independent risk factors of poor outcomes. Patients on anticoagulants for underlying comorbidities also have worse outcomes.
ICH is the type of stroke with highest mortality. Literature review showed 35% of patients who present with hemorrhagic stroke die within 30 days, and 25% die within the first 2 days following stroke. Not only does it have high mortality, one of the research studies showed that only 20% of the patients who experience hemorrhagic stroke are independent at 6 months.
Patients should be counseled to know about early signs of stroke. These include presence of facial droop, strange speech, and asymmetrical weakness in one of the extremities and should be told to call 911 right away without any delay.
Patients should be counseled to stop smoking, stop use of illegal drugs and asked to control blood pressure aggressively.
VI. Patient Safety and Quality Measures
A. Core Indicator Standards and Documentation.
All patients with cerebro-vascular accidents should undergo a speech/swallow evaluation (dysphasia screen), along with physical/occupational therapy evaluation.
During the hospital stay, patients should have appropriate DVT prophylaxis and smoking cessation counseling. Patients should be assessed for rehabilitation and should have a rehabilitation plan discussed with the patient or/and care taker. Also, the patient and/or family/care taker should be extensively educated about hemorrhagic stroke and its outcome.
B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.
In general, about 50% of the patients who survive stroke (including ICH and ischemic stroke) are permanently disabled at the time of discharge and need long term rehabilitation and closer follow-up. Literature review showed 30% of the patients with stroke are known to be readmitted to the hospital within the first year after discharge, mostly due to infectious causes. Other causes include another stroke and cardiovascular events.
The three most common infections are pneumonia, urinary tract infection and infections of the bed sores, and are usually related to residual neurological deficits. Closer monitoring, either at skilled nursing facility or by trained nurses at home, can help avoid these infections.
One of the recently published studies showed a significant decrease in hospital admissions (from complications of stroke) with closer outpatient follow-ups. Aggressive pulmonary toilet, straight urinary catheterization and frequent change in positions are some maneuvers which can help with avoiding these infections, in turn avoiding frequent admissions to the hospital.
Appropriate control of blood pressure by medications and/or life style modifications such as diet (salt restriction, low fat diet) and exercise (weight loss) can help avoid re-bleeds. Attention should also be given to quit smoking, alcohol and drug abuse and also on control of blood sugar in patients with previous hemorrhagic strokes.
What's the evidence?
Qureshi, AI, Tuhrim, S, Broderick, JP. "Medical Progress: Spontaneous Intracerebral Hemorrhage". N Engl J Med. vol. 344. 2001. pp. 1450-1460.
Flaherty, ML, Tao, H, Haverbusch, M. "Warfarin use leads to larger intracerebral hematomas". Neurology. vol. 71. 2008. pp. 1084.
Kim, JS, Lee, JH, Lee, MC. "Small primary intracerebral hemorrhage: clinical presentation of 28 cases". Stroke. vol. 25. 1994.[Erratum, Stroke 1994;25:2098.]
Tellez, H, Bauer, RB. "Dexamethasone as treatment in cerebrovascular disease. 1. A controlled study in intracerebral hemorrhage". Stroke. vol. 4. 1973. pp. 541-6.
Gujjar, AR, Deibert, E, Manno, EM, Duff, S, Diringer, MN. "Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: timing, and outcome". Neurology. vol. 51. 1998. pp. 447-51.
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