Intracerebral Hemorrhage

Background

• Intracerebral hemorrhage (ICH), a type of stroke, is a medical emergency in which bleeding in the brain, caused by ruptured blood vessels or hemorrhagic lesions, leads to brain tissue damage, clinical symptoms, and, in some patients, death.
  • In primary ICH, reported in 78%-88% of cases, damaged small arteries or arterioles rupture, usually due to hypertension or cerebral amyloid angiopathy.
  • Secondary ICH can arise from any of several conditions, such as, rupture of aneurysm or vascular malformation, hemorrhagic tumor, or cerebral venous thrombosis.
• ICH comprises about 6%-20% of all strokes and has a reported incidence of 24.6 per 100,000 person-years.
• Hypertension is the strongest risk factor for ICH. Other modifiable and potentially modifiable risk factors include cigarette smoking, heavy alcohol intake, poor diet, use of anticoagulants or antiplatelets, increased high-density lipoprotein (HDL) cholesterol, low total cholesterol, low non-HDL cholesterol, diabetes, and chronic kidney disease. Apolipoprotein E gene (APOE) e2 and e4 alleles, male sex, African ethnicity, and Asian ethnicity are also associated with an increased risk.

Evaluation

• Suspect stroke in patients with characteristic symptoms of acute onset headache, nausea and/or vomiting, a depressed mental state, focal neurological deficits, and decreasing alertness and consciousness.
• Perform immediate neuroimaging with non-contrast head computed tomography (CT) (preferred) or magnetic resonance imaging (MRI) to distinguish intracerebral hemorrhage from ischemic stroke (Strong recommendation) and to confirm diagnosis, location, and extent of hemorrhage.
• Determine the clinical severity with a validated scale, such as the National Institutes of Health Stroke Scale (NIHSS) or the Glasgow Coma Scale (GCS) (Strong recommendation).
• Measure blood glucose upon arrival and immediately correct hypoglycemia if present (Strong recommendation). Hypoglycemia is a possible cause of symptoms and should be ruled out.
• Conduct additional testing, but this should not delay evaluations to distinguish ischemic stroke from intracerebral hemorrhage:
  • Consider additional/repeat neuroimaging such as
    • CT angiography or contrast-enhanced CT to help identify patients at risk for hematoma expansion based on presence of contrast within hematoma (spot sign).
    • CT angiography and other modalities to evaluate for secondary causes such as vascular malformation or tumor (especially in younger patients without cardiovascular disease risk factors or coagulopathy).
    • Serial head CT scans within first 24 hours to evaluate for hemorrhage expansion.
  • Order blood tests and urine studies to evaluate for coagulopathy, sympathomimetic drugs such as cocaine, kidney function, and possible comorbidities.
  • Perform electrocardiography for cardiac screening.
  • Conduct swallowing screen.
  • Assess for seizure activity.

Management

• Blood pressure (BP) management:
  • If systolic BP of 150-220 mm Hg and no contraindications to BP treatment, reduce systolic BP to about 140 mm Hg (Strong recommendation).
  • If systolic BP > 220 mm Hg, consider aggressive BP reduction with a continuous IV infusion and frequent BP monitoring (Weak recommendation).
  • Options for lowering BP include IV labetalol 5-20 mg bolus (repeat as indicated but do not exceed 300 mg), IV nicardipine 5 mg/hour slow infusion (titrated by 2.5 mg/hour as indicated but do not exceed 15 mg/hour).
• Coagulation and hemostasis management:
  • For patients with severe coagulation factor deficiency, give appropriate coagulation factor replacement therapy (Strong recommendation).
  • For patients on anticoagulants or antiplatelets:
    • Discontinue the medication (Strong recommendation).
    • If vitamin K antagonist and elevated INR, give reversal vitamin K plus prothrombin complex concentrate (PCC) (or fresh frozen plasma if PCC is not available) (Strong recommendation).
    • If other medications, consider reversal based on individual patient and medication.
    • The optimal timing for resuming anticoagulant or antiplatelet therapy is uncertain.
    • Uncertain usefulness of platelet transfusion in patients with history of antiplatelet use.
• General supportive care for intracerebral hemorrhage (ICH) should include frequent vital sign checks, neurological assessments, airway support and maintenance, and continuous cardiopulmonary monitoring. Also consider treating fever with medication.
  • Monitor glucose levels and avoid hyperglycemia and hypoglycemia (Strong recommendation).
  • Venous thromboembolism prophylaxis:
    • Start intermittent pneumatic compression on the first day of hospital admission to reduce risk of thromboembolism (Strong recommendation).
    • Also consider low-dose subcutaneous low-molecular weight heparin or unfractionated heparin at 24-48 hours after ICH onset, if hemorrhage has stabilized (Weak recommendation).
  • Screen for dysphagia before initiating oral intake and closely monitor for changes in swallowing function (Strong recommendation).
• Other management options for specific patient populations:
  • Consider monitoring intracranial pressure (ICP) if moderate-to-severe ICH or intraventricular hemorrhage and reduced level of consciousness (Weak recommendation).
    • Potential management options are borrowed from strategies for traumatic brain injury and include sedation (propofol or barbiturates), external ventricular drainage, cerebrospinal fluid drainage, and intubation with hyperventilation.
    • See Elevated Intracranial Pressure in Adults for additional information.
  • For control of seizures, start antiseizure medications (Strong recommendation). The choice of medication depends on the individual patient including other medications and comorbidities; consider IV lorazepam at 0.05-0.1 mg/kg and possibly supplemental IV phenytoin 20 mg/kg, IV fosphenytoin 20 mg/kg, or IV levetiracetam 50 mg/kg. Do not routinely give prophylactic antiseizure medication in asymptomatic patients (Strong recommendation).
  • For associated intraventricular hemorrhage, consider ventricular drainage, intraventricular fibrinolysis, or endoscopic evacuation.
  • Surgical evacuation can be considered for some patients, particularly in patients with deteriorating condition and/or hemorrhage in or near cerebellum.
    • For posterior fossa hemorrhage, perform craniotomy for surgical evacuation if ≥ 1 of neurologic deterioration, brainstem compression, or hydrocephalus from ventricular obstruction (Strong recommendation).
    • For supratentorial ICH, consider minimally invasive hematoma evacuation hemeatoma is > 20-30 mL and Glasgow Coma Scale score 5-12 points (Weak recommendation).
  • Consider decompressive craniectomy with or without hematoma evacuation in patients with supratentorial hemorrhage if the patient is in a coma, has a large hematoma with significant midline shift, or has elevated ICP refractory to nonsurgical management (Weak recommendation).
  • Continuous electroencephalogram monitoring is probably indicated if seizures are suspected or patient has unexplained abnormal or fluctuating mental status.
• Other management considerations:
  • Establish the goals of care with the patient and/or a designated decision-maker (Strong recommendation).
  • If there are no preexisting documented requests for limitations on life-sustaining treatment, consider aggressive care, including postponing new do not attempt resuscitation (DNAR) orders and postponing withdrawal of medical support until ≥ 2 full days of hospitalization (Strong recommendation).
  • If the patient has DNAR status, do not limit other medical and surgical interventions, unless explicitly specified by patient or surrogate(s), because sucha limitation may increase mortality (Strong recommendation).
  • Treat all patients with ICH in a stroke or neuro-intensive care unit, preferably one with neuroscience intensive care expertise (Strong recommendation).