Hemorrhagic stroke

Background

• ~10% of all acute strokes
• Warfarin use is significant risk factor
  • Accounts for 5-15% of all cases
  • Risk of ICH doubles for each 0.5 increase in INR above 4.5

Risk Factors

1. HTN
2. AVM
3. Aneurysm
4. Anticoagulant therapy
5. Sympathomimetic drugs
6. Intracranial tumors
7. Amyloid angiopathy
8. Smoking

Clinical Features

• Often clinically indistinguishable from SAH, ischemic stroke
  • More likely to have rapidly progressive symptoms
• HA and N/V often precede the neurologic deficit
• Findings dictated by location of bleed (in order of most common)
  • Putamen
  • Thalamus
  • Pons
  • Cerebellum

Work-Up

• Head CT (non-con)
• Labs
  • CBC
  • Chem
  • Coags
  • T&S
• ECG

Management

1. Elevating head of bed to 30 degrees (if pt not hypotensive)
2. Blood pressure
   1. SBP >200 or MAP >150
      1. Consider aggressive reduction w/ continuous IV infusion
   2. SBP >180 or MAP >130 and evidence or suspicion of elevated ICP
      1. Consider reducing BP using intermittent or continuous IV meds to keep CPP >60-80
   3. SBP >180 or MAP >130 and NO evidence or suspicion of elevated ICP
      1. Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)
3. Reverse coagulopathy
   1. Heparin
      1. Give protamine 1mg/100units of heparin based on time since last dose
   2. Warfarin
      1. Reverse regardless of INR
      2. Prothrombin complex concentrate 20-50mg/kg IV x1 OR
      3. FFP + vit K 10mg IV over 10min
   3. ASA/clopidogrel
      1. Desmopressin (0.3mcg/kg)
      2. Platelets
   4. Fondaparinux or Rivaroxaban
      1. rFVIIa 2mg (40 mcg/kg)
      2. OR PCC 25-50 U/kg
      3. Don't give both 2/2 to prothrombotic effects
   5. Dabigatran
      1. rFVIIa 100 mcg/kg
      2. OR PCC 25-50 U/kg
      3. Consider DDAVP 0.3 mcg/kg
      4. Hemodialysis, if feasible

See Also

• SAH
• CVA

Source

• Tintinalli
• EMcrit Podcast 17
• ebmedicine.net- Coag in ICH