HEMISPHERES VI - HEMORRHAGIC STROKE –
INPATIENT QUESTIONS AND ANSWERS
10%
Intracerebral Hemorrhage (ICH) Occurs when an intracerebral blood vessel bursts leaking
blood inside the brain tissue
3%
Occurs when a blood vessel in the subarachnoid space
Subarachnoid Hemorrhage (SAH)
ruptures causing blood to leak into this space and cer-
brospinal fluid surrounding the brain
Anticoagulation/coagulopathy reversal - as warranted
Blood pressure control - acute lowering to target SBP 140
General focus of ICH managment Seizure control - treat clinical seizures only
Complication management - expansion of hematoma, el-
evated ICP hydrocephalus, herniation
Anticoagulation reversal
BP control - target SBP <160 to prevent rebleeding
Aneurysm repair - endovascular coiling or surgical clip-
ping
Subarachnoid Hemorrhage (SAH) general focus Seizure control - prophylaxis may be considered when
high risk characteristics are present
Complication management - rebleeding, cerebral va-
sospasm, delayed cerebral ischemia, hydrocephalus, and
elevated intracranial pressure
Ruptured MCA aneurysm, high-grade aSAH, ICH, hydro-
High risk characteristics for seizure prophylaxis
cephalus or cortical infarction
Cardiopulmonary instability or post arrest
Cerebral ischemia -from vasospasm
Active seizures
Potential ICH/SAH presentation on arrival
Active hemorrhage - post reperfusion
Active herniation
Hypo/hyperglycemia
1/5
, HEMISPHERES VI - HEMORRHAGIC STROKE –
INPATIENT QUESTIONS AND ANSWERS
Electrolyte imbalance-hyponatremia
Hyperthermia
When is reversal of anticoagulants required ICH stroke patients with INR >1.4
When to consider activated charcoal for anticoagulant
if most recent oral anticoagulant dose was < 2 hrs
reversal
4 factor prothrombin complex concentrate (PCC) and IV vit
Warfarin Reversal K
Fresh frozen plasma if 4 factor PCC unavailable
Idarucizumab
Direct Thrombin Inhibitor reversal Dabigatran 4 Factor PCC or activated PCC (aPCC) and consider renal
replacement therapy if idarucizumab unavailable
Andexanet alfa
Factor Xa inhibitor Reversal - apixaban and rivaroxaban
4 factor PCC or activated PCC (aPCC) if andexanet alfa
reversal
unavailable
Factor XA inhibitor Reversal - edoxaban and betrixaban
4-factor PCC or aPCC
reversal
Hematoma or infarct
Causes of increased ICP stroke related Aneurysm
Obstructive hydrocephalus
Headache, vision or speech changes
Altered LOC, mental status, declining GCS
Vomiting, seizures
S/S of increased ICP Dilated unresponsive pupils
Posturing - decorticate, decerebrate, flaccid
Cushing's triad - hypertension, bradycardia, irregular res-
pirations
GCS score <8
ICP monitor inserted in ventricles warranted if
Evidence of herniation
2/5
INPATIENT QUESTIONS AND ANSWERS
10%
Intracerebral Hemorrhage (ICH) Occurs when an intracerebral blood vessel bursts leaking
blood inside the brain tissue
3%
Occurs when a blood vessel in the subarachnoid space
Subarachnoid Hemorrhage (SAH)
ruptures causing blood to leak into this space and cer-
brospinal fluid surrounding the brain
Anticoagulation/coagulopathy reversal - as warranted
Blood pressure control - acute lowering to target SBP 140
General focus of ICH managment Seizure control - treat clinical seizures only
Complication management - expansion of hematoma, el-
evated ICP hydrocephalus, herniation
Anticoagulation reversal
BP control - target SBP <160 to prevent rebleeding
Aneurysm repair - endovascular coiling or surgical clip-
ping
Subarachnoid Hemorrhage (SAH) general focus Seizure control - prophylaxis may be considered when
high risk characteristics are present
Complication management - rebleeding, cerebral va-
sospasm, delayed cerebral ischemia, hydrocephalus, and
elevated intracranial pressure
Ruptured MCA aneurysm, high-grade aSAH, ICH, hydro-
High risk characteristics for seizure prophylaxis
cephalus or cortical infarction
Cardiopulmonary instability or post arrest
Cerebral ischemia -from vasospasm
Active seizures
Potential ICH/SAH presentation on arrival
Active hemorrhage - post reperfusion
Active herniation
Hypo/hyperglycemia
1/5
, HEMISPHERES VI - HEMORRHAGIC STROKE –
INPATIENT QUESTIONS AND ANSWERS
Electrolyte imbalance-hyponatremia
Hyperthermia
When is reversal of anticoagulants required ICH stroke patients with INR >1.4
When to consider activated charcoal for anticoagulant
if most recent oral anticoagulant dose was < 2 hrs
reversal
4 factor prothrombin complex concentrate (PCC) and IV vit
Warfarin Reversal K
Fresh frozen plasma if 4 factor PCC unavailable
Idarucizumab
Direct Thrombin Inhibitor reversal Dabigatran 4 Factor PCC or activated PCC (aPCC) and consider renal
replacement therapy if idarucizumab unavailable
Andexanet alfa
Factor Xa inhibitor Reversal - apixaban and rivaroxaban
4 factor PCC or activated PCC (aPCC) if andexanet alfa
reversal
unavailable
Factor XA inhibitor Reversal - edoxaban and betrixaban
4-factor PCC or aPCC
reversal
Hematoma or infarct
Causes of increased ICP stroke related Aneurysm
Obstructive hydrocephalus
Headache, vision or speech changes
Altered LOC, mental status, declining GCS
Vomiting, seizures
S/S of increased ICP Dilated unresponsive pupils
Posturing - decorticate, decerebrate, flaccid
Cushing's triad - hypertension, bradycardia, irregular res-
pirations
GCS score <8
ICP monitor inserted in ventricles warranted if
Evidence of herniation
2/5
