Intracerebral

Intracerebral hemorrhage (ICH)

Initial care

= airway
= cardiovascular support
= rapid transport to acute stroke care facility.
= monitored and managed in an intensive care unit
= need expertise in neurology, neurosurgery, neuroradiology, and critical care

Reversal of anticoagulation

Stop all anticoagulant and antiplatelet

Heparin associated ICH:
Protamine sulfate: slow IV infusion (< 20 mg/minute and no more than 50 mg over any 10-minute period).

Reverse Warfarin

Reverse NOAC

Severe coagulation factor deficiency or thrombocytopenia
consider appropriate factor replacement or platelet transfusion

Patient on antiplatelet therapy
platelet transfusions not indicated

Blood pressure management

= For systolic blood pressure (SBP) 150 - 220 mmHg, acute lowering to 140 mmHg
= For SBP >220 mmHg: iv antihypertensive medication and frequent (every five minutes) blood pressure monitoring to SBP of 140 to 160 mmHg

Gerneral care:
= Intermittent pneumatic compression
= Normal saline initially
= Avoid Hypervolemia
= Treat sources of fever. Prophylactic antibiotic use does not improve outcomes
= Dysphagia, npo
= Treat Hyperglycemia, glucose level between 140 to 180 mg/dL
= Seizure management — risk of seizures 15 percent
If a seizure occurs, use appropriate intravenous antiseizure drug treatment
- Prophylactic seizure medication not indicated.

Intracranial pressure management

= Head of the bed 30 degrees
= Mild sedation, as needed for comfort
= Avoid endotracheal tube holder and securement device ties, constrictive central line dressings
= Avoid twisting of the head that might constrict cervical veins
= Use normal saline initially; avoid hypotonic fluid
= Glucocorticoids should NOT be used to lower the ICP
= ICP monitoring:
- if Glasgow Coma Scale (GCS) score <8
- - or clinical evidence of transtentorial herniation
- - or significant intraventricular hemorrhage or hydrocephalus
- - goal of cerebral perfusion pressure (CPP) of 50 to 70 mmHg.
= Hydrocephalus: consider ventriculostomy

= Hyperventilation
- rapid lowering of ICP by inducing cerebral vasoconstriction
- PaCO2 goal of >30 to 35 mmHg
More aggressive hyperventilation (ie, a PaCO2 of 26 to 30 mmHg) may result in brain ischemia and worse outcomes

= Osmotic therapy
- Mannitol: initial bolus of 0.5 to 1 g/kg IV, then 0.25 to 0.5 g/kg as needed, every four to twelve hours
-- monitor serum osmolality, goal 300 - 310 mosmol/kg
-- should not exceed 250 mg/kg every four hours; higher doses can cause acute renal failure.
- Hypertonic saline: 3 percent, continuous infusion titrated to a sodium goal of approximately 145 to 155 mEq/L.
may cause circulatory overload and pulmonary edema, increased chloride burden, metabolic acidosis

= Pharmacologic coma.
Propofol:
- reduces intracranial pressure
- easily titrated
- short half-life.
- only for ventilated patients
- loading dose 1 - 3 mg/kg and continued as an infusion
- typically at 5 to 50 mcg/kg per minute, with a maximum dose of 200 µg/kg per minute.
- Hypotension is common; treat with intravenous fluids and/or vasopressors
- Propofol infusion syndrome: a rare complication with high doses >4 mg/kg per hour and prolonged use >48 hours
-- acute refractory bradycardia, metabolic acidosis, cardiovascular collapse, rhabdomyolysis, hyperlipidemia, renal failure, and hepatomegaly.

= Neuromuscular blockade
- sometimes employed to reduce ICP in patients who are not responsive to analgesia and sedation alone
- - muscle activity can contribute to increased ICP

Indications for Surgery

Cerebellar hemorrhage
= cerebellar hemorrhage greater than 3 cm in diameter, or
deteriorating neurologically or
brainstem compression and/or hydrocephalus due to ventricular obstruction

Supratentorial hemorrhage
- Surgical hematoma is controversial;
Features that support surgery include a recent onset of hemorrhage, ongoing clinical deterioration, and location of the hematoma near the cortical surface.
Features in favor of less aggressive therapy: serious concomitant medical problems, advanced age, stable clinical condition, remote onset of hemorrhage, involvement of the dominant hemisphere, and inaccessibility of the hemorrhage

After acute phase
Early mobilization and rehabilitation
Resumption of antiplatelet therapy
= probably safe to resume antiplatelet therapy after the acute phase
if blood pressure is controlled
indication for antiplatelet treatment is sufficiently strong
if potential benefit outweighs the increase in risk of recurrent ICH.
Cerebral amyloid angiopathy, aspirin use may be associated with a greater risk of recurrent ICH

Aspirin or antiplatelets for those patients with only an "average" risk of recurrent ischemic stroke}
"average" risk: hypertension, diabetes, hypercholesterolemia, and the absence of heart disease to be markers of average risk.
“above average risk”: Atrial fibrillation, cardiomyopathy, large vessel extracranial and intracranial stenoses, and malignancy may benefit from long-term antiplatelet therapy after ICH.

Resumption of anticoagulation
2015 American Heart Association/American Stroke Association (AHA/ASA) guidelines suggest delaying oral anticoagulants for at least four weeks after onset of the ICH

= treating hypertension is the most important step to reduce ICH
stopping smoking, heavy alcohol use, and illicit drug use
treatment of obstructive sleep apnea are also recommended
no compelling reason to discontinue statin agents in the acute or chronic phase of ICH.

PROGNOSIS

Mortality and functional outcome
= 30-day mortality 35 to 52 percent
= Hakf of these deaths occur in the first two days
= pooled 1 and 5 year survival: 46 and 29 percent respectively
= Independent function at one year 17 - 25 percent (54 to 57 percent of survivors)

Risk factors for poor outcomes
= Increasing age
= Low Glasgow Coma Scale (GCS) score
= High ICH volume
- volume of 60 cm3 or greater on initial CT and a GCS score < 8m a 30-day mortality of 91 percent.
- volume less than 30 cm3 and a GCS score of nine or more predicted a 30-day mortality of 19 percent.
= Intraventricular hemorrhage
= Deep or infratentorial ICH location
= Preceding oral anticoagulation therapy, and possibly antiplatelet therapy
= Early neurologic deterioration within 48 hours
- An ICH
= Hematoma growth — particularly within the first 24 hours
= extensive white matter lesions on CT or MRI are associated with worse outcomes

ICH score
Add each category
•GCS score 3 to 4 (= 2 points); GCS 5 to 12 (= 1 point) and GCS 13 to 15 (= 0 points)
•ICH volume =30 cm3 (= 1 point), ICH volume <30 cm3 (= 0 points)
•Intraventricular extension of hemorrhage present (= 1 point); absent (= 0 points)
•Infratentorial origin yes (= 1 point); no (= 0 points)
•Age =80 (= 1 point); <80 (= 0 points)

Thirty-day mortality rates for ICH scores of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100 percent, respectively.

A modified ICH score using the National Institutes of Health Stroke Scale (NIHSS) score (table 5) in place of the GCS score may be a better predictor of good outcome than the original ICH score

Risk factors for recurrent ICH

= Annual risk of recurrent bleed 1-7%
= Uncontrolled hypertension
= Lobar location of initial ICH
= Older age
= male
= Ongoing anticoagulation
= Apolipoprotein E epsilon 2 or epsilon 4 alleles
= Greater number of microbleeds on MRI
= Ischemic stroke history
= Black race
= Hispanic ethnicity

Index