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.

Emergency Measures

  • Ensure the status of the patient’s airway, breathing and circulation
    • Intubate if insufficient ventilation (pO2 <60 mmHg/7.9 kPa or pCO2 >50 mmHg/6.3 kPa), cyanosis, impending respiratory failure, obvious aspiration risk, or depressed level of consciousness
  • Detection of focal neurological deficits
  • Detection of signs of external trauma
  • Admit in an intensive care unit (ICU) or acute stroke unit for at least the 1st 24-72 hours

Blood Pressure Management

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-related acute hypertension that reduces 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 and suspected high intracranial pressure on CT scan, monitor continuously intracranial pressure, blood pressure and 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 antihypertensive IV infusion and frequent blood pressure monitoring may be considered in patients presenting with systolic blood pressure of >220 mmHg
BP Level Recommendations
SBP >220 mmHg or MAP >150 mmHg Aggressive reduction of blood pressure with continuous IV medications
Monitor blood pressure every 5 minutes
SBP between 150 and 220 mmHg without contraindication to acute BP treatment Reduce SBP to 140 mmHg
SBP = systolic blood pressure; MAP = mean arterial pressure
Modified from:
Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2040.


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

Coagulation Management of Intracerebral Hemorrhage

  • Discontinue immediately all anticoagulants and antiplatelets after the onset of intracerebral hemorrhage and reverse the anticoagulation effect with appropriate agents; however, carefully weigh the risk of bleeding against the risk of thrombosis if anticoagulation is stopped or reversed
  • Prothrombin complex concentrate, factor IX complex concentrate, fresh frozen plasma (FFP) and recombinant activated factor VII (rFVIIa) normalize the laboratory elevation of the international normalized ratio (INR) very rapidly
  • Treat patients with severe coagulation factor deficiency with appropriate factor replacement
  • Patients with thrombocytopenia and severe coagulation factor deficiency should receive platelet transfusion
    • Platelet transfusion should be avoided in patients on antiplatelet therapy
  • It is recommended that patients with elevated INR, due to intake of oral anticoagulants, should stop warfarin, replace vitamin K-dependent factors, correct INR, and start IV vitamin K
  • Decision to restart antithrombotic therapy after intracerebral hemorrhage (ICH) related to antithrombotic therapy depends on the risk of subsequent arterial or venous thromboembolism, the risk of recurrent intracerebral hemorrhage, and the overall state of the patient
    • After confirming bleeding cessation, low-dose subcutaneous unfractionated Heparin or low-molecular-weight Heparin may be started after 1-4 days of onset to prevent deep venous thrombosis in immobile patients

Recombinant Activated Factor VII (rFVIIa)

  • Can rapidly normalize INR in oral anticoagulant-associated hemorrhages but does not replace all clotting factors
  • Treatment option for patients ≤ 70 years of age with baseline ICH volume <60 mL, intraventricular hemorrhage volume <5 mL and time from onset-to-treatment ≤ 2.5 hours
  • Not recommended as routine treatment for Warfarin reversal

Vitamin K

  • Adjunct therapy to OAC-associated hemorrhages

Fresh Frozen Plasma (FFP)

  • Limited by risk of allergy, infection, processing time and volume required for correction

Prothrombin Complex Concentrates (PCC)

  • Considered as an alternative to fresh frozen plasma
  • May be considered as a possible intervention to reverse life-threatening direct oral anticoagulant-associated bleeding
  • Advantages: Rapid reconstitution and administration, high concentration of coagulation factors (eg II, VII, IX and X) in small volume, and less infections

Tranexamic acid

  • A hemostatic agent that may be considered for use in patients with spontaneous intracerebral hemorrhage and a possible intervention to reverse direct oral anticoagulant-associated bleeding 

Protamine sulfate

  • Used to reduce bleeding tendency in patients with Heparin-associated ICH, with the dose depending on the dose of Heparin and the time since Heparin has been given

Warfarin-associated Intracerebral Hemorrhage

  • Should be treated with intravenous vitamin K (IV vitamin K)
  • Treatment should also aim to replace clotting factors with FFP or a four-factor PCC

Other Agents

  • Other hemostatic agents currently undergoing clinical trials include activated factor X (FXa), Andexanet alpha,  Ciraparantag, and Desmopressin

Elevated Intracranial Pressure (ICP) Management

  • Elevated intracranial pressure (ICP): ICP >20 mmHg for >5 minutes
  • Goal ICP <20 mmHg and cerebral perfusion pressure (CPP) 50-70 mmHg
  • Monitor intracranial pressure using ventricular catheter
  • Intracranial pressure monitoring may be considered in the following patients: Glasgow Coma Scale (GCS) score of <8, clinical evidence of transtentorial herniation, significant intraventricular hemorrhage, and hydrocephalus
  • Treatment should include a balanced and graded approach beginning with simple measures to more aggressive therapies
  • Recommended step-by-step approach for ICP >20-25 mmHg:
    • Cerebrospinal fluid (CSF) drainage
    • Mannitol or hypertonic saline bolus
    • Sedation
    • Neuromuscular blockade
    • Consider mild hyperventilation
    • Hypothermia, hemicraniectomy, barbiturate coma
  • Consider repeat computed tomography (CT) scan if intracranial pressure is still >20-25 mmHg
  • Withdraw intracranial pressure therapies once ICP <20 mmHg

Head-of-Bed Elevation

  • Keep head of bed elevated at 30° with patient’s neck in neutral position to maximize venous outflow, lowering intracranial pressure

Analgesia and Sedation

  • Titrate to minimize pain and increase in intracranial pressure while allowing evaluation of clinical status
    • Can be achieved with IV Propofol, Etomidate, or Midazolam for sedation and Morphine or Alfentanil for analgesia

Cerebrospinal Fluid (CSF) Drainage

  • Effective especially in the setting of hydrocephalus
  • Used when an intraventricular catheter is in place to monitor intracranial pressure

Osmotic Therapy

  • Target serum osmolality: 300-320 mOsm/kg
  • Should only be used in patients with type B intracranial pressure waves, progressively increasing intracranial pressure waves or clinical deterioration associated with mass effect
  • Mannitol is the most commonly used intravenous (IV) osmotic agent
    • Produces lowering of intracranial pressure within 20 minutes of administering an IV bolus
  • Furosemide may be administered simultaneously to maintain osmotic gradient
  • Hypertonic saline solutions have been shown to reduce intracranial pressure, even in cases refractory to hyperventilation and Mannitol

Neuromuscular Blockade

  • Used with sedation and/or analgesia to prevent elevated intracranial pressure due to increased intrathoracic pressure and obstruction in cerebral venous outflow
  • Nondepolarizing agents: Eg Vecuronium or Pancuronium

Hyperventilation

  • One of the most effective methods to rapidly reduce intracranial pressure
    • Reserved for use as a temporizing measure while awaiting more definitive treatments
  • Reduction of PaCO2 to 30–35 mmHg lowers intracranial pressure by 25-30% in most patients
  • Intracranial pressure reduction may take up to 30 minutes to occur after PaCO2 is changed
  • Failure of intracranial pressure to respond to hyperventilation indicates a poor prognosis

Barbiturate Coma

  • Depresses cerebral metabolic activity which reduces cerebral blood flow and intracranial pressure
  • Barbiturates effectively reduce brain swelling
    • Eg Pentobarbital, Thiopental
    • Safe limit ≈10 mg/kg/day

Treatment of Other Medical Conditions

Elevated Glucose

  • High blood glucose on admission predicts an increased fatality rate in both non-diabetic and diabetic patients with intracerebral hemorrhage (ICH)
  • Monitoring of glucose level is important; normoglycemia should be maintained
  • Hypoglycemia and hyperglycemia should be avoided

Seizures

  • The majority of seizures occur within the 1st 24 hours of intracerebral hemorrhage onset
  • Clinical (or proven subclinical) seizures or patients with a change in mental status with electrographic seizures on electroencephalography (EEG) should be treated with antiepileptic drugs
  • Continuous electroencephalography monitoring may be indicated in patients with depressed mental status that is disproportionate to the degree of brain injury
  • Anticonvulsant can usually be discontinued after 1 month in patients who do not suffer from further seizures
    • Long-term treatment with anticonvulsant may be necessary if patients experience seizures >2 weeks after intracerebral hemorrhage
  • Prophylactic treatment is not recommended

Body Temperature

  • Fever (temperature >38.5°C) is a common occurrence in patients with intracerebral hemorrhage and increased fever duration is associated with poor outcomes
  • Fever should be aggressively treated even as appropriate testing for systemic infection is being undertaken
    • May use cooling blankets and Paracetamol [intravenous (IV)/per orem (PO)/rectal]

Other General Measures

  • Fluid management, nutrition, and prevention of aspiration pneumonia and bed sores are the same as for patients with ischemic stroke
    • Use normal saline for fluid replacement and maintenance, avoid hypotonic fluids
  • Use of intermittent pneumatic compression with elastic stockings is advised to prevent deep venous thrombosis 
  • Prophylactic administration of H2 blockers or drugs that can protect the mucosa decreases the incidence of gastric hemorrhage; routine use should be avoided due to increased risk of hospital-acquired pneumonia and enteric infections
  • It is generally recommended to do full aggressive care early (ie the 1st day) after intracerebral hemorrhage onset and postponement of new do-not-resuscitate (DNR) orders until at least the 2nd full day of hospitalization
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