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)