Management of Intracranial Hemorrhage

Steven Podnos MD

Epidemiology

• Cerebral Catastrophe• Overall Mortality 40%• Only 25% of survivors are independent at 6

months

Pathophysiology

• 85% occurs as spontaneous event related to rupture of small penetrating arteries damaged by hypertension and/or amyloid angiopathy

Presentation

• ICH is an evolving process, with hematoma enlargement in almost 75% of patients in first 24 hours

• Management strategies :• Prevention of further bleeding/hematoma

expansion• Minimize cerebral ischemia

ICH

• Evidence suggests that control of BP improves outcomes

• Intubation for GCS equal to or less than 8• ICU care• Reversal of Anticoagulation-Vit K, FFP• Platelet dysfunction due to Plavix/ASA causes

increased risk for ICH, but platelet transfusion has not been shown to be of benefit

HBP

• In contrast to Ischemic CVA, BP control is felt to be important in preventing hematoma expansion

• Guidelines: Keep CPP > 60, reduce SPB to 160, MAP 110 with monitoring

Other Modalities

• No consensus on ICP monitoring or Rx• Seizures occur in 4-9%. Prophylactic meds not

indicated. Rx seizures actively however. Consider subclinical seizures in patients with poor consciousness

• Glycemic Control-suggest only control glucose over 180. Avoid hypoglycemia

Other Modalities Rx in ICH

• SCD on admit• Use chemical agent for DVT prophylaxis 1-4

days after bleeding felt to have stopped• Temperature control reasonable but

unproven. No data on hypothermia yet.• Neurosurgery-Ventriculostomy for

hydrocephalus. Other surgery (hematoma evacuation) in study.

Neuroprotection in ICH

• No good data