Intracerebral Haemorrhage

Intracerebral Haemorrhage

26/7/10

Richon, F. et al (2008) “Clinical review: Critical care management of spontaneous hemorrhage” Critical Care 12:237, pages 1-15

CLASSIFICATION

Primary – spontaneous rupture of small penetrating arterioles damaged by chronic hypertension or amyloid (85%)

Secondary – AVM, post infarct bleeding, tumours, coagulopathy, trauma, vasculitis (15%)

- if blood gets into ventricular system -> obstructive hydrocephalus

RISK FACTORS

- HT

- heavy ET-OH intake

- cocaine use

- advanced age

- male

- African-American

- Japanese

- ?low cholesterol

- ?smoking

DIAGNOSIS

- non-contrast CT

- MRI

- angiography: aneurysms, AVM’s, vein thrombosis, vasculitis

MANAGEMENT

Goals:

(1) prevent haematoma expansion and complications

(2) prevent secondary injury

Resuscitate

A: secure airway – good data to support

B: ventilatory support – good data to support

C:

- blood pressure control – aim for SBP <140 (labetalol, esmolol, nicardipine – data to show that aggressive BP control reduces haematoma expansion + no real prenumbra in ICH)

- N/S for fluid – this is the current recommendations

Treatment

Specific

- reversal ofany preexisting coagulopathy (aim for an INR < 1.4):

-> stop warfarin

-> FFP 15mL/kg

-> prothrombin X 25-50IU/kg (factors II, IX, X)

-> vitamin K 5mg IV (onset 6 to 24 hours) -> important for sustained reversal

-> FVIIa controversial (significant decrease in haematoma size with slight decrease in mortality but increase in thromboembolism risk)

-> can restart anticoagulation @ 10 days

- revere anti-platelet effect:

-> DDAVP

-> platelet transfusion

- external ventricular drainage – if unconscious -> EVD, regular urokinase and tPA seems to help although still under investigation

- surgical evacuation – no benefit demonstrated and increase harm (STICTH), still under investigation (STICH II)

- hemicraniectomy – sounds promising -> better controlled studies are required

- dexamethasone (corticosteroids) – avoid

General

- head up

- intracranial pressure monitoring – aim CPP 70-90 (controversial)

- osmotherapy –23.4% saline 0.5-2.0mL/kg

- fever control – aim T < 38.3 C, patients who have higher temperatures have poorer outcomes

- seizure prophylaxis – lorazepam 0.1mg/kg, phenytoin 20mg/kg

- avoidhyperglycemia – relatively aggressively

- nutritional supplementation – N/J tube

- DVT Prophylaxis – can give on SC heparin 5000U BD on day 2 without increasing ICH

Underlying Cause

- infection: antimicrobials

- neoplasm: resection + oncology/radiology assessment

- metastasis: find primary

- vasculitis: immunomodulation

- hypertensive: antihypertensives

- SAH: find cause (aneurysm, AVM)

Disposition

- early referral to a neurointensive care

- mobilization of retrieval services

- family meeting

Jeremy Fernando (2011)