Intracerebral Haemorrhage

Clinical Context ICH accounts for up to 15% of first-time strokes and is associated with a 30-day mortality rate between 35% and 52%. Half of deaths related to ICH occur within the first 2 days, and the rate of mortality declines subsequently. Only 20% of patients with ICH can expect to maintain functional independence 6 months after the hemorrhage event.

Diagnosis  Classic symptoms of ICH include the sudden onset of a focal neurologic deficit, which progresses over minutes to hours. Vomiting is more common with ICH than with ischemic stroke or subarachnoid hemorrhage.  Either CT or MRI may be used for initial neuroimaging of patients suspected of having ICH, but MRI may be more difficult to perform because of impaired consciousness, vomiting, or agitation.

Causes of worsening Rebleeding Vasogenic edema Hydrocephalus Transtentorial herniation is the mode of death in massive hemorrhage

Mortality 30 day mortality Parenchymal >60cm3 & GCS <8 - 90% 9 – 20% Cerebellar: - 2cm & less cerebellar signs do well - 3cm & progressive drowsiness do poorly without intervention - >3cm poor prognosis regardless of trt

Management  In patients with normal BP hypertension resolves over the first week  If systolic blood pressure exceeds 200 mm Hg in a patient with ICH, continuous intravenous antihypertensive therapy should be considered. A target blood pressure of 160/90 mm Hg is reasonable. (labetalol)  Treatment of elevated ICP should begin with conservative measures, such as elevation of the head of the bed, analgesia, and sedation. Further steps can include osmotic therapy with mannitol or hyperventilation, which can be associated with hypovolemia and decreased cerebral blood flow, respectively.

Initial Medical Therapy Monitoring and management of patients with an ICH should take place in an intensive care unit setting because of the acuity of the condition, frequent elevations in ICP and blood pressure, frequent need for intubation and assisted ventilation, and multiple complicating medical issues (Class I, Level of Evidence B).

Antiepileptics Appropriate antiepileptic therapy should always be used for treatment of clinical seizures in patients with ICH (Class I, Level of Evidence B). A brief period of prophylactic antiepileptic therapy soon after ICH onset may reduce the risk of early seizures in patients with lobar hemorrhage (Class IIb, Level of Evidence C). It is generally agreed that sources of fever should be treated and antipyretic medications should be administered to lower temperature in febrile patients with stroke (Class I, Level of Evidence C).

Rehabilitation As for patients with ischemic stroke, early mobilization and rehabilitation are recommended in patients with ICH who are clinically stable (Class I, Level of Evidence C).

ICP Treatment of elevated ICP should include a balanced and graded approach that begins with simple measures, such as elevation of the head of the bed and analgesia and sedation. More aggressive therapies to decrease elevated ICP, such as osmotic diuretics (mannitol and hypertonic saline solution), drainage of CSF via ventricular catheter, neuromuscular blockade, and hyperventilation, generally require concomitant monitoring of ICP and blood pressure with a goal to maintain CPP >70 mm Hg (Class IIa, Level of Evidence B).

Hyperglycemia Evidence indicates that persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke is associated with poor outcomes, and thus it is generally agreed that hyperglycemia should be treated in patients with acute stroke. Guidelines for ischemic stroke suggest that elevated glucose concentrations (>185 mg/dL and possibly >140 mg/dL) probably should trigger administration of insulin, similar to the procedure in other acute situations accompanied by hyperglycemia. Use of these guidelines for ICH as well is reasonable. The results of ongoing research should clarify the management of hyperglycemia after stroke (Class IIa, Level of Evidence C).

Suggested Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH Until ongoing clinical trials of blood pressure intervention for ICH are completed, physicians must manage blood pressure on the basis of the present incomplete evidence. Current suggested recommendations for target blood pressures in various situations and potential medications are (Class IIb, Level of Evidence C).

Suggested Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH If SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of blood pressure with continuous intravenous infusion, with frequent blood pressure monitoring every 5 minutes. If SBP is >180 mm Hg or MAP is >130 mm Hg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous medications to keep cerebral perfusion pressure >60 to 80 mm Hg.

Suggested Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH If SBP is >180 mm Hg or MAP is >130 mm Hg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of blood pressure (eg, MAP of 110 mm Hg or target blood pressure of 160/90 mm Hg) using intermittent or continuous intravenous medications to control blood pressure, and clinically reexamine the patient every 15 minutes.

Drug Intravenous Bolus DoseContinuous Infusion Rate Labetalol 5 to 20 mg every 15 min2 mg/min (maximum 300 mg/d) Enalapril 1.25 to 5 mg IVP every 6 h * NA Hydralazine 5 to 20 mg IVP every 30 min1.5 to 5 µg · kg –1 · min –1 Nitroglycerin NA20 to 400 µg/min Esmolol 250 µg/kg IVP loading dose25 to 300 µg · kg –1 · min –1 Intravenous Medications That May Be Considered for Control of Elevated Blood Pressure in Patients With ICH

rFVIIa Treatment with rFVIIa within the first 3 to 4 hours after onset to slow progression of bleeding has shown promise in one moderate-sized phase II trial; however, the efficacy and safety of this treatment must be confirmed in phase III trials before its use in patients with ICH can be recommended outside of a clinical trial (Class IIb, Level of Evidence B).

Management-DVT Prophylaxis Patients with hemiparesis or hemiplegia following ICH should receive prophylaxis with intermittent pneumatic compression stockings. These patients may receive low-molecular- weight heparin after 3 to 4 days following cessation of bleeding. Patients with ICH who develop acute proximal venous thrombosis should be considered for acute placement of a vena cava filter.

Management of Coagulation & Fibrinolysis Issues Patients who develop ICH while receiving warfarin should receive intravenous vitamin K. Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII can reduce patients' international normalized ratio very rapidly and with less fluid infusion vs fresh frozen plasma, but these newer therapies are associated with a higher risk for thromboembolism. The decision of whether to reinitiate warfarin therapy following ICH should be individualized based on the patient's risk for repeat ICH and thromboembolism. Warfarin may be restarted 7 to 10 days following ICH among patients at high risk for thromboembolism.

Fibrinolysis Post Thrombolysis 2 units of FFP for factor V & VII 20 units of cryoprecipitate fibrinogen 6 units of Platelets Post Heparin Protamine 1 mg IV push for 100 u heparin over last hours LMWH – Protamine 50 mg Aminocaproic acid 5 g over 1 hr

Surgery  Surgical intervention should be considered for patients with cerebellar hemorrhage of 3 cm or greater who are deteriorating neurologically.  Patients with brainstem compression or ventricular obstruction resulting from hemorrhage may also be considered for surgical intervention.  Patients with lobar clots within 1 cm of the surface may be considered for evacuation of ICH with craniotomy.