Chapter 109. Management of Patient with Intracerebral Hemorrhage (ICH)

• 12–31 per 100,000 people
• 10–30% of all strokes
• Six-month mortality rate of 30–50%
• Only 20% regain functional independence at end of 6 months

• Men
• African-Americans, Japanese
• Low LDL cholesterol, Hypertension
• Excessive alcohol consumption
• Anticoagulation

• Ischemic stroke with hemorrhagic conversion
• Amyloid angiopathy (age >60 years)
• Chronic hypertension
• Coagulopathy
• AV malformation, cavernous angioma, neoplasm, dural sinus thrombosis with hemorrhage
• Vasculopathy
• Trauma

• Hemorrhages continue to grow and expand over several hours after onset of symptoms (hematoma growth)
• Most of the brain injury and swelling that happens after ICH is the result of inflammation caused by thrombin and other coagulation end-products

• Determine if any predisposing illness – cancer, hypertension, smoking, trauma, dementia (amyloid), vascular malformations (aneurysm, AVM), anticoagulation (warfarin, heparin, LMWH), anti platelet medications, renal disease (uremic platelets), liver disease (abnormal coagulation parameters – prothrombin time), hematologic disease, recreational drug abuse (cocaine), seizure disorder, CVA, hemophilia, von Willebrand’s disease
• History – sudden onset of focal neurological deficit, which progresses over minutes to hours, headache, vomiting
• Physical examination
  • Vitals: elevated systolic blood pressure > 160 mm Hg, temperature > 37.5°C associated with growth of hematoma
  • HEENT: look for signs of injury (laceration, fracture, scars) on the head
  • Cardiovascular: rule out atrial fibrillation and other arrhythmias
  • CNS: detailed neurological exam-assess mental status, cranial nerves, sensory, motor, and cerebellar exam

See Clinical Evaluation.

• PT for patients on warfarin
• PTT to rule out von Willebrand’s disease
• Platelet count for thrombocytosis or thrombocytopenia
• Liver function test, fibrinogen, D dimer,
• Chemistry
• Urine toxicology screen
• Type and cross match sample

• Imaging
  • Non-contrast computed tomography (CT) scan or magnetic resonance imaging (MRI) (whichever is faster to obtain) to assess:
    • Location of blood (deep, superficial, cerebellar, intraventricular)
    • Volume of blood ([A × B × C]/2)
    • Presence of hydrocephalus, midline shift
  • CT scan is better at evaluating ventricular extension
  • CT angiography for aneurysm, arteriovenous malformation
  • MRI is better at detecting underlying structural lesions and delineating perihematomal edema and herniation
• ICP monitoring (see Chapter 98)
  • Especially helpful in patients with decreased level of consciousness

• Emergency management
  • Airway evaluation for rapid neurological decline and necessity for endotracheal intubation
    • Failure to recognize leads to aspiration, hypoxemia, hypercapnia (with increased ICP and downward spiral)
    • For rapid sequence intubation, choose sedatives (propofol) and neuromuscular blockers (rocuronium; cisatracurium if indicated) that do not raise ICP. Consider topical lidocaine to suppress cough reflex
    • Avoid excessive hyperventilation to PCO2 below 28 mm Hg as it leads to increased vasoconstriction and brain ischemia
• Blood pressure
  • Maintain SBP between 160 and 180 mm Hg or MAP < 130 mm Hg
    • Cardene        infusion, 5–15 mg/h or
    • Labetalol      5–20 mg bolus and infusion at 2 mg/h or
    • Esmolol        250 mcg/kg IV loading, maintenance at 25–300 mcg/kg/min
    • Avoid nitroprusside (can raise ICP)
  • Hypotension
    • Isotonic fluid bolus
    • Vasopressors (norepinephrine or phenylephrine) if needed to maintain a CPP of >60–80 mm Hg
• Lowering ICP (See Chapter 98)
  • Head of bead ...