The surgical management of intracerebral and subarachnoid hemorrhages is too extensive to describe in detail here, but basic aspects of medical management will be reviewed briefly. Of 3 published treatment guidelines that dealt with childhood stroke,28–30
only one dealt with hemorrhagic stroke. 30
Many of the steps that follow were adapted from the single published guideline for children and supplemented by guidelines for adult hemorrhagic stroke.31,32
Whether these measures actually improve outcomes has not been rigorously examined in children. Whether adult-based recommendations are appropriate for children will need to be confirmed in future studies.
A patient with an acute hemorrhagic stroke should be monitored in an intensive care unit staffed by physicians and nurses with neuroscience expertise. While an awake patient may be monitored noninvasively, patients who progress to or present with significant alteration of consciousness should have intracranial pressure monitoring, and cerebral perfusion pressure should be maintained between 50 mm Hg to 70 mm Hg. Any further clinical deterioration should be promptly evaluated with a CT scan to look for acute hydrocephalus, extension of an intracerebral hematoma, herniation, or vasospasm in a patient with subarachnoid hemorrhage. Protective reflexes may be impaired so that the stability of the airway must be ensured. If there is loss of respiratory drive, loss of protective airway reflexes, or cardiorespiratory instability, the patient should be intubated and mechanically ventilated. Intravenous access is important to maintain circulatory homeostasis and to prevent dehydration. Hypotonic fluids may contribute to cerebral edema so they should be avoided in favor of with normal saline fluids. As stroke may impair swallowing, nothing should be given by mouth until the risk of aspiration can be adequately assessed in the alert patient.
There is no present evidence that hypothermia improves outcome after intracerebral hemorrhage. Studies in adults have shown an association between hyperthermia and poorer outcome in ischemic stroke,33,34
but there has been little investigation of this association in hemorrhagic stroke. Animal studies do not show a clear link between hyper- or hypothermia and outcome after experimental intracerebral hemorrhage.35–37
Two small studies in adults38,39
suggested a link between hyperthermia and poorer outcome of hemorrhagic stroke, but one study used historical controls and the other found that fever was confounded by intraventricular hemorrhage. Despite the lack of evidence, treating hyperthermia to achieve normal temperature seems reasonable.
Clinically significant hypertension occurs far less frequently in children with hemorrhagic stroke than in adults. Upon presentation to an emergency department, 27% of adult patients with intracerebral hemorrhage have blood pressures greater than 160/100 mm Hg.40
In the 4-case series noted above, hypertension was considered to be the cause of intracranial hemorrhage in only 3 of 195 children. Therefore, many of the adult guidelines do not apply to children. When blood pressures are substantially higher than age-specific norms treatment is reasonable, but overly rapid reduction of blood pressure may compromise cerebral perfusion. The prudent recommendation is that treatment of elevated blood pressure should be gradual and should avoid hypotension or compromise of cerebral perfusion pressure.
Severe increased intracranial pressure or compartmental herniation can expand the zone of injury and lead to further neurologic deterioration. One should suspect severe edema or mass effect with increased intracranial pressure if there is deterioration in the level of consciousness, the appearance of periodic breathing, or pupillary asymmetry. If these clinical changes occur, repeat CT scan imaging may be necessary to distinguish the effects of increasing cerebral edema from rebleeding or rupture of hemorrhage into the ventricles.
Hyperosmotic treatment with mannitol can lower intracranial pressure, but the effect tends to decrease over time. Hypertonic saline (7.2% saline with hydroxyethyl starch; 10% or 23.4% saline) has been used in patients with increased intracranial pressure after traumatic brain injury. Hypertonic (10%) saline, was effective in reducing intracranial pressure when mannitol was no longer effective in a small series of ischemic stroke patients. 41
Three small trials found that hypertonic saline was slightly more effective than mannitol in lowering intracranial pressure in patients with stroke or brain injury.42–44
Despite initial positive reports favoring hypertonic saline over mannitol, neurointensivists remain split between the use of mannitol versus hypertonic saline. 45
Vasogenic edema sometimes occurs after a cerebral hemorrhage. Corticosteroids are not helpful with cytotoxic edema, but individuals with vasogenic edema may benefit from corticosteroids.