1. Management of Spontaneous ICH Corey Heitz, MD Director, Undergrad Med Ed Assistant Professor, Emergency Medicine

2. Disclosures none

3. Objectives Become familiar with 2015 ICH guidelines Discuss evidence basis for main recommendations Provide initial management to ICH pts

5. I take coumadin

7. What are the questions? Best imaging Blood pressure control Stop the bleeding Seizure prophylaxis Evacuation/drainage

8. Imaging CT and MRI are equally sensitive (I, A) MRI is better for subacute blood CTA/MRA/venography (IIb, B) SAH Calcifications at margins Venous hyperattenuation Unusual shape Edema out of proportion Lobar hemorrhage <55yo No history of htn

9. What are the questions? Best imaging Blood pressure control Stop the bleeding Seizure prophylaxis Evacuation/drainage

10. Blood Pressure Control Lowering BP to 140mmHg is safe (I, A) Lowering BP to 140mmHg may improve functional outcomes (IIb, C) If >220mmHg, IV infusion may be effective (IIb, C) What drug?

11. What are the questions? Best imaging Blood pressure control Stop the bleeding Seizure prophylaxis Evacuation/drainage

12. I’m having a seizure!!

13. Seizure management Treat seizures (I, A) Treat patients with AMS and EEG positive (I, C) Continuous EEG probably recommended if AMS out of proportion to ICH (IIa, C) Do not prophylax (III, B)

14. What are the questions? Best imaging Blood pressure control Stop the bleeding Seizure prophylaxis Evacuation/drainage

15. Stop the bleeding! Replace factors and/or platelets (I, C) Hold VKA, give IV vit K, correct INR (I,C) PCCs are faster and fewer side effects (IIb, B) rFVIIa not recommended (III, C)

16. Stop the bleeding! NOACs: PCCs or rFVIIa are options (IIb, C) Activated charcoal if <2 hrs since last dose (IIb, C) Protamine if on heparin (IIb, C) Use of platelets unclear if using antiplatelets

17. What are the questions? Best imaging Blood pressure control Stop the bleeding Seizure prophylaxis Evacuation/drainage

18. Evacuation/Drainage Hydrocephalus with AMS (IIb, B) GCS <8, herniation, significant IVH Cerebellar bleeds w herniation, decompensation need surgery (I, B) Early evac not better than waiting for decomp (IIb, A)

19. What are the questions? Best imaging Blood pressure control Stop the bleeding Seizure prophylaxis Evacuation/drainage

20. Others Swallow studies should be performed Initial severity scale (NIHSS or other; I, B) Avoid hyper/hypoglycemia No role for corticosteroids

22. Control BP No seizure meds Reverse INR Initial severity Swallow screen Admit to ICU/neuro unit