intracerebral%20hemorrhage
INTRACEREBRAL HEMORRHAGE
Intracerebral hemorrhage is the sudden burst of blood into the brain tissue itself.
It causes sudden onset of focal neurological deficit.
The focal neurologic findings are related to the anatomic location, size and speed of development of intracerebral hemorrhage.
Neurological deficit usually progresses over a minute to an hour.
Rapid recognition and diagnosis of intracerebral hemorrhage are essential because of its frequently rapid progression.

Prevention

Elevated Blood Pressure Management

  • Lowering blood pressure (BP) reduces the risk of rebleeding and may prevent expansion of the hematoma
    • Several studies have shown that treatment of intravenous (IV) Nicardipine or Labetalol in patients with intracerebral hemorrhage (ICH) related acute hypertension that reduces systolic blood pressure (SBP) to 110-140 mmHg in the first 24 hours after intracerebral hemorrhage is well tolerated and associated with a reduced risk of hematoma expansion, neurological deterioration, and in-hospital mortality
  • Patients with mean arterial pressure (MAP) ≥130 mmHg may receive IV or per orem (PO) antihypertensives
  • If blood pressure is lowered too rapidly, cerebral perfusion pressure (CPP) may drop and cause brain injury especially if intracranial pressure is increased
  • In patients with high blood pressure & suspected high intracranial pressure on CT scan, monitor continuously intracranial pressure, blood pressure & cerebral perfusion pressure
  • Acute lowering of systolic blood pressure to 140 mmHg, in patients with small to moderate size, non-surgical intracerebral hemorrhage presenting with systolic blood pressure of 150-220 mmHg, may be considered safe and can be effective for improving functional outcome
  • Aggressive reduction of blood pressure with a continuous IV infusion and frequent blood pressure monitoring may be considered in patients presenting with systolic blood pressure of >220 mmHg

Low Blood Pressure Management

Volume Replenishment

  • 1st-line therapy to treat low blood pressure in stroke patient
  • Monitor with central venous pressure (CVP) or pulmonary wedge pressure

Phenylephrine, Dopamine or Norepinephrine

  • May be used if volume replacement fails to correct hypotension

Prevention of Recurrence

Risk Factors for Recurrence

  • Initial intracerebral hemorrhage (ICH) location
    • Lobar is the most common in amyloid angiopathy
    • Location of hypertensive vasculopathy (eg basal ganglia, thalamus and brainstem)
  • Old age
  • Post-ICH anticoagulation
    • Associated with increased risk of recurrence
    • Avoidance of long term anticoagulation as treatment for nonvascular atrial fibrillation (AF) after spontaneous lobar intracerebral hemorrhage
    • Antiplatelet treatment may be a safer option to anticoagulation after all types of intracerebral hemorrhage
  • Presence of apolipoprotein E ε2 or E ε4 alleles
  • Presence of greater number of microbleeds on magnetic resonance imaging (MRI) scan
  • Hypertension
    • Target blood pressure (BP) <140/90 mm Hg or <130/80 mmHg for those with diabetes or chronic kidney disease
    • Blood pressure control with antihypertensives particularly for those whose bleed was in a typical location of hypertensive vasculopathy
  • Heavy alcohol intake
    • >2 drinks/day increases risk of recurrence
  • Insufficient evidence on use of statins or physical or sexual activity
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