A 69-year-old male presents to the emergency department for slurred speech and an inability to use his right arm which occurred while he was eating dinner. The patient arrived at the emergency department within one hour. A CT scan was performed of the head and did not reveal any signs of hemorrhage. The patient is given thrombolytics and is then managed on the neurology floor. Three days later, the patient is recovering and is stable. He seems depressed but is doing well with his symptoms gradually improving as compared to his initial presentation. The patient complains of neck pain that has worsened slowly over the past few days for which he is being given ibuprofen. Laboratory values are ordered and return as indicated below: Serum: Na+: 130 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 7 mg/dL Glucose: 70 mg/dL Creatinine: 0.9 mg/dL Ca2+: 9.7 mg/dL Urine: Appearance: dark Glucose: negative WBC: 0/hpf Bacterial: none Na+: 320 mEq/L/24 hours His temperature is 99.5°F (37.5°C), pulse is 95/min, blood pressure is 129/70 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

Continue conservative management

A 74-year-old man presents to the emergency department by paramedics for slurred speech and weakness in the left arm and leg for 1 hour. The patient was playing with his grandson when the symptoms started and his wife immediately called an ambulance. There is no history of head trauma or recent surgery. The patient takes captopril for hypertension. The vital signs include: pulse 110/min, respiratory rate 22/min, and blood pressure 200/105 mm Hg. The physical examination shows that the patient is alert and conscious, but speech is impaired. Muscle strength is 0/5 in the left arm and leg and 5/5 in the right arm and leg. A non-contrast CT of the head shows no evidence of intracranial bleeding. The lab results are as follows: Serum glucose 90 mg/dL Sodium 140 mEq/L Potassium 4.1 mEq/L Chloride 100 mEq/L Serum creatinine 1.3 mg/dL Blood urea nitrogen 20 mg/dL Cholesterol, total 240 mg/dL HDL-cholesterol 38 mg/dL LDL-cholesterol 100 mg/dL Triglycerides 190 mg/dL Hemoglobin (Hb%) 15.3 g/dL Mean corpuscular volume (MCV) 83 fL Reticulocyte count 0.8% Erythrocyte count 5.3 million/mm3 Platelet count 130,000/mm3 Partial thromboplastin time (aPTT) 30 sec Prothrombin time (PT) 12 sec Although he is within the time frame for the standard therapy of the most likely condition, the treatment cannot be started because of which of the following contraindications?

Systolic blood pressure of 200 mm Hg

A platelet count of 130,000/mm3

A 23-year-old man presents with a blunt force injury to the head from a baseball bat. He is currently unconscious, although his friends say he was awake and speaking with them en route to the hospital. He has no significant past medical history and takes no current medications. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 165/85 mm Hg, pulse 50/min, and respiratory rate 19/min. On physical examination, there is a blunt force injury to the left temporoparietal region approximately 10.1–12.7 cm (4–5 in) in diameter. There is anisocoria of the left pupil, which is unresponsive to light. The patient is intubated and fluid resuscitation is initiated. A noncontrast computed tomography (CT) scan of the head is acquired and shown in the exhibit (see image). Which of the following is the most appropriate medical treatment for this patient?

Placement of a ventriculoperitoneal (VP) shunt

Placing the head of the bed at 0 degrees

A 48-year-old woman is brought to the emergency department because of a 1-hour history of sudden-onset headache associated with nausea and vomiting. The patient reports she was sitting at her desk when the headache began. The headache is global and radiates to her neck. She has hypertension. She has smoked one pack of cigarettes daily for the last 10 years. She drinks alcohol occasionally. Her father had a stroke at the age 58 years. Current medications include hydrochlorothiazide. She is in severe distress. She is alert and oriented to person, place, and time. Her temperature is 38.2°C (100.8°F), pulse is 89/min, respirations are 19/min, and blood pressure is 150/90 mm Hg. Cardiopulmonary examination shows no abnormalities. Cranial nerves II–XII are intact. She has no focal motor or sensory deficits. She flexes her hips and knees when her neck is flexed while lying in a supine position. A CT scan of the head is shown. Which of the following is the most appropriate intervention?

Administer intravenous alteplase

Administer intravenous vancomycin and ceftriaxone

Perform decompressive craniectomy

Hemorrhagic stroke management for USMLE Step 2 CK: High-Yield Management Lessons

Initial Workup - Code Red, Brain Bleed

ABCs first: Secure airway, breathing, circulation.
Immediate non-contrast CT head: The single most important initial test.
Vitals & Neuro Exam: Glasgow Coma Scale (GCS), NIH Stroke Scale (NIHSS).
Key Labs: Stat coagulation panel (PT/INR, aPTT), CBC, platelets, glucose.
Blood Pressure: Keep SBP <160 mmHg initially; use IV labetalol or nicardipine.

Non-contrast CT showing acute intracerebral hemorrhage

⭐ Non-contrast CT is paramount. Thrombolytics (for ischemic stroke) are absolutely contraindicated in hemorrhagic stroke and would be catastrophic.

Acute BP & Coags - The First Hour

Immediate Goal: Aggressively lower BP and reverse any coagulopathy to limit hematoma expansion, the primary driver of early neurological deterioration.
Blood Pressure Control:
- Target Systolic BP <140 mmHg.
- Use easily titratable IV agents like Labetalol or Nicardipine.
Coagulopathy Reversal:
- Warfarin: Vitamin K + 4-factor Prothrombin Complex Concentrate (4F-PCC).
- DOACs: Use specific reversal agents (Idarucizumab for Dabigatran; Andexanet Alfa for Xa inhibitors).
- Antiplatelets: Platelet transfusions are generally not recommended but may be considered for patients requiring neurosurgery.

⭐ For warfarin reversal, 4F-PCC is superior to FFP. It provides faster INR correction with a lower infusion volume, minimizing the risk of fluid overload.

ICH vs. SAH - Two Flavors of Trouble

Intracerebral Hemorrhage (ICH)
- Cause: Chronic hypertension → Charcot-Bouchard microaneurysms; cerebral amyloid angiopathy.
- Presentation: Focal neurological deficits that worsen over minutes to hours.
- CT Finding: Blood within the brain parenchyma.
- Management: Strict BP control (target SBP <140 mmHg), reverse anticoagulation.
Subarachnoid Hemorrhage (SAH)
- Cause: Ruptured saccular (berry) aneurysm (85%).
- Presentation: Sudden, explosive "worst headache of my life"; meningeal signs.
- CT Finding: Blood in cisterns and sulci.
- Management: Nimodipine for vasospasm prevention; surgical clipping or endovascular coiling.

CT scans of various intracranial hemorrhages

⭐ Nimodipine in SAH does not prevent re-bleeding but is critical to prevent delayed cerebral ischemia from vasospasm, a major cause of morbidity/mortality days after the initial event.

Complications - Watching for Waves

Re-bleeding: Highest risk in first 24h; sudden neurological decline, ↑ mortality.
Vasospasm: Peaks 4-14 days post-SAH. Causes delayed cerebral ischemia. Prevent with nimodipine.
Hydrocephalus: Obstructive/communicating due to blood in ventricles/cisterns. May require external ventricular drain (EVD).
Seizures: Can occur due to cortical irritation from blood. Prophylaxis is controversial.
Hyponatremia: From SIADH or cerebral salt wasting.

⭐ Nimodipine is the only drug shown to improve outcomes in SAH by preventing vasospasm-related ischemia, but it does not reduce the incidence of vasospasm itself.

Cerebral angiography showing vasospasm post-SAH

High-Yield Points - ⚡ Biggest Takeaways

Immediate BP control is the first crucial step; aggressively lower to SBP < 140 mmHg.

Urgently reverse any anticoagulation; use Vitamin K, FFP, or prothrombin complex concentrates (PCC).

Secure emergent neurosurgical consultation for potential hematoma evacuation.

Manage elevated intracranial pressure (ICP) with head elevation, mannitol, and hyperventilation.

Seizure prophylaxis is often indicated, particularly for lobar hemorrhages.

Non-contrast CT is the essential first diagnostic step to differentiate from ischemic stroke.

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Hemorrhagic stroke management