3. Indication of Vascular Imaging
• Subarachnoid hemorrhage
• Normotensive
• Hypertensive with atypical site (lobar
hemorrhage)
• Recurrent hemorrhage in same site
• Young patient
9. Fig. “Spot sign” in intracerebral hemorrhage on CT angiography.
Baseline (A) and 24-hour (C) noncontrast CT scans show expansion of a
right caudate hemorrhage with ventricular extension. CT angiography at
baseline (B) shows an area of contrast extravasation (“spot sign”)
suggestive of ongoing bleeding (arrow)
A B C
11. Medical management
• Supportive and Nursing Care
• Blood Pressure
• Reversal of coagulopathy
• ICP monitoring and treatment
• Glucose Management
• Fever and Temperature control
• Seizures control
• Management of Complications
12. General Monitoring and Nursing Care
• Initial monitoring and management of ICH patients
should take place in an intensive care unit or dedicated
stroke unit with physician and nursing neuroscience
acute care expertise
(Class I; Level of Evidence B)
13. Blood Pressure
• SBP between 150 to 220 mmHg and without contraindication
to acute BP treatment, acute lowering of SBP to 140 mmHg is
safe
(Class I; Level of Evidence A)
And can be effective for improvement functional outcome
(Class Ila; Level of Evidence B)
• For ICH patients presenting with SBP >220 mmHg, it may be
reasonable to consider aggressive reduction of BP with a
continuous intravenous infusion and frequent BP monitoring
(Class IIb; Level of Evidence C)
14. Anticoagulation-related Hemorrhage
• Patients with ICH whose INR is elevated because of VKA should
have their VKA withheld, receive therapy to replace vitamin K–
dependent factors and correct the INR, and receive intravenous
vitamin K.
(Class I; Level of Evidence C)
• PCCs may have fewer complications and correct the INR more
rapidly than FFP and might be considered over FFP.
(Class IIb; Level of Evidence B)
• rFVIIa does not replace all clotting factors and though INR may
be lowered, clotting may not be restored in vivo; therefore,rVIIa
is not recommended for VKA reversal in ICH
(Class III;Level of Evidence C)
15. Anticoagulation-related Hemorrhage
• For patients with ICH who are taking dabigatran, rivaroxaban,
or apixaban, treatment with PCCs, or rFVIIa might be
considered on an individual basis.
• Activated charcoal might be used if the most recent dose of
dabigatran, apixaban, or rivaroxaban was taken <2 hours
earlier. Hemodialysis might be considered for dabigatran .
(Class IIb; Level of Evidence C)
• Protamine sulfate may be considered to reverse heparin in
patients with acute ICH
(Class IIb; Level of Evidence C)
16. Antiplatelet Medication-related
Intracerebral Hemorrhage
• The usefulness of platelet transfusions in ICH patients with a
history of antiplatelet use is uncertain
(Class IIb; Level of Evidence C)
• Although rFVIIa can limit the extent of hematoma expansion
in noncoagulopathic ICH patients, there is an increase in
thromboembolic risk with rFVIIa and no clear clinical benefit
in unselected patients. Thus, rFVIIa is not recommended
(Class III; Level of Evidence A).
17. Coagulopathy-related Hemorrhage
• Patients with a severe coagulation factor deficiency or severe
thrombocytopenia should receive appropriate factor
replacement therapy or platelets, respectively
(Class I; Level of Evidence C)
18. Thromboprophylaxis in Intracerebral
Hemorrhage
• Patients with ICH should have intermittent pneumatic
compression for prevention of venous thromboembolism
beginning the day of hospital admission (Class I; Level of
Evidence A). Graduated compression stockings are not
beneficial to reduce DVT or improve outcome
(Class III; Level of Evidence A)
• After documentation of cessation of bleeding, low dose
subcutaneous low-molecular-weight heparin or
unfractionated heparin may be considered for prevention of
venous thromboembolism in patients with lack of mobility
after 1 to 4 days from onset
(Class IIb; Level of Evidence B)
19. Thromboprophylaxis in Intracerebral
Hemorrhage
• Systemic anticoagulation or IVC filter placement is probably
indicated in ICH patients with symptomatic DVT or PE (Class
IIa; Level of Evidence C). The decision between these 2 options
should take into account several factors, including time from
hemorrhage onset, hematoma stability, cause of hemorrhage
and overall patient condition
(Class IIa; Level of Evidence C)
20. ICP Monitoring and Treatment
• Patients with a GCS score of ≤8, those with clinical evidence of
transtentorial herniation, or those with significant IVH or
hydrocephalus might be considered for ICP monitoring and
treatment. A CPP of 50 to 70 mm Hg may be reasonable to be
maintained.
(Class IIb; Level of Evidence C)
• Corticosteroids should not be administered for treatment of
elevated ICP in ICH
(Class III; Level of Evidence B)
• Ventricular drainage as treatment for hydrocephalus is
reasonable, especially in patients with decreased level of
consciousness
(Class IIa; Level of Evidence B)
21. Seizure
• Clinical seizures should be treated with antiseizure drugs
(Class I; Level of Evidence A)
• Patients with a change in mental status who are found to have
electrographic seizures on EEG should be treated with
antiseizure drugs
(Class I; Level of Evidence C)
• Continuous EEG monitoring is probably indicated in ICH
patients with depressed mental status that is out of
proportion to the degree of brain injury
(Class IIa; Level of Evidence C)
• Prophylactic antiseizure medication is not recommended
(Class III; Level of Evidence B)
22. Surgical Treatment of ICH
• Patients with cerebellar hemorrhage who are deteriorating
neurologically or who have brainstem compression and/or
hydrocephalus from ventricular obstruction should undergo surgical
removal of the hemorrhage as soon as possible
(Class I; Level of Evidence B)
Initial treatment of these patients with ventricular drainage rather
than surgical evacuation is not recommended
(Class III; Level of Evidence C)
• For most patients with supratentorial ICH, the usefulness of surgery
is not well established
(Class IIb; Level of Evidence A)
• A policy of early hematoma evacuation is not clearly beneficial
compared with hematoma evacuation when patients deteriorate
(Class IIb; Level of Evidence A)
23. Surgical Treatment of ICH
• Supratentorial hematoma evacuation in deteriorating patients
might be considered as a life-saving measure
(Class IIb; Level of Evidence C)
• Decompressive Craniectomy with or without hematoma
evacuation might reduce mortality for patients with
supratentorial ICH who are in a coma, have large hematomas
with significant midline shift, or have elevated ICP refractory
to medical management
(Class IIb; Level of Evidence C)
• The effectiveness of minimally invasive clot evacuation with
stereotactic or endoscopic aspiration with or without
thrombolytic usage is uncertain
(Class IIb; Level of Evidence B)
24. Management of Medical
Complications
• Most common complications were Pneumonia (5.6%),
Aspiration (2.6%),Respiratory failure/distress (2%), PE (1.3%),
and Sepsis (1.7%)
• Other medical complications in patients with ICH include
cardiac events and death caused by acute Myocardial
infarction, Heart failure, Ventricular arrhythmias, Cardiac
arrest, Acute kidney failure, Hyponatremia, Gastrointestinal
bleeding, and Post-stroke depression
.
25. Management of Medical
Complications
• A formal screening procedure for dysphagia should be
performed in all patients before the initiation of oral intake to
reduce the risk of pneumonia
(Class I; Level of Evidence B)
• Systematic screening for myocardial ischemia or infarction
with electrocardiogram and cardiac enzyme testing after ICH
is reasonable
(Class IIa; Level of Evidence C)
26. Prevention of Recurrent ICH
• When stratifying a patient’s risk for recurrent ICH may affect
management decisions, it is reasonable to consider the following
risk factors for ICH recurrence: (1) lobar location of the initial
ICH; (2) older age; (3) presence and number of microbleeds on
gradient echo MRI; (4) ongoing anticoagulation
(Class IIa; Level of Evidence B)
• BP should be controlled in all ICH patients (Class I; Level of
Evidence A). Measures to control BP should begin immediately
after ICH onset. A long-term goal of BP <130 mm Hg systolic and
80 mm Hg diastolic is reasonable
(Class IIa; Level of Evidence B)
27. Prevention of Recurrent ICH
• Lifestyle modifications, including avoidance of alcohol use greater
than 2 drinks per day, tobacco use, and illicit drug use, as well as
treatment of obstructive sleep apnea, are probably beneficial
(Class IIa; Level of Evidence B)
• Avoidance of long-term anticoagulation with warfarin as a
treatment for nonvalvular atrial fibrillation is probably
recommended after warfarin-associated spontaneous lobar ICH
because of the relatively high risk of recurrence
(Class IIa; Level of Evidence B)
• Anticoagulation after nonlobar ICH and antiplatelet monotherapy
after any ICH might be considered, particularly when there are
strong indications for these agents
(Class IIb; Level of Evidence B)
28. Prevention of Recurrent ICH
• The optimal timing to resume oral anticoagulation after anticoagulant-
related ICH is uncertain. Avoidance of oral anticoagulation for at least 4
weeks, in patients without mechanical heart valves, might decrease the
risk of ICH recurrence
(Class IIb; Level of Evidence B)
If indicated, aspirin monotherapy can probably be restarted in the days
after ICH, although the optimal timing is uncertain
(Class IIa; Level of Evidence B)
• The usefulness of dabigatran, rivaroxaban, or apixaban in patients with
atrial fibrillation and past ICH to decrease the risk of recurrence is
uncertain
(Class IIb; Level of Evidence C)
• There are insufficient data to recommend restrictions on the use of
statins in ICH patients
(Class IIb; Level of Evidence C)
29. Rehabilitation and Recovery
• Given the potentially serious nature and complex pattern of
evolving disability and the increasing evidence for efficacy, it
is recommended that all patients with ICH have access to
multidisciplinary rehabilitation
(Class I; Level of Evidence A)
• Where possible, rehabilitation can be beneficial when begun
as early as possible and continued in the community as part of
a well-coordinated (“seamless”) program of accelerated
hospital discharge and home-based resettlement to promote
ongoing recovery
(Class IIa; Level of Evidence B)
30. Scoring systems for prediction of outcome
in intracerebral hemorrhage (ICH score)
majority of fatalities occur in the first two days of the onset of symptoms .Rapid initial diagnosis and concentrated management are crucial in the early management of ICH.
When a patient presents with focal neurological deficits, severe headache, vomiting, high systolic blood pressure (SBP) greater than 220 mmHg, and decreased level of consciousness with a sudden onset, ICH should be the first condition considered in the diagnosis and rapid assessment with history ,examintion and neuroimaging should be done
Presentation
Previously well. Sudden headache, vomiting and left sided weakness.
Patient Data
AGE: 40 years
Non-contrast CT of the brain demonstrates a large right temporo-parietal haemorrhage. It is associated with moderate midline shift.
GENDER: Male
Right common carotid artery angiogram demonstrates a ~1.5cm nidus supplied predominantly by the right middle cerebral artery. The AVM has superficial drainage via markedly enlarged cortical veins, which drain in the dural sinuses. No deep drainage was identified.
Left parietal arteriovenous malformation. Upper left: T2-weighted MR1 shows a tangle of vessels interspersed throughout the parietal lobe. The largest of these vessels are dilated draining veins. Upper right: CT angiography demonstrates enhancement of the abnormal vessels throughout the left hemisphere. The AVM is fed primarily v i a branches of the left MCA. Cerebral angiography. Contrast injected into the left internal carotid artery reveals the feeding arteries (lower left) and abnormal early filling of dilated draining veins (lower riglrt) due to blood bypassing the capillary bed
Cavernous mal formation in the right parietal lobe. Axial T2 MRI (left) shows a round lesion which is
heterogeneously hyperintense and hypointense. This appearance is due to vascular channels which are immediately
adjacent to each other without interspersed normal brain tissue, containing blood products in different stages of
degradation. An axial gradient echo MRI (right) shows that the lesion is hypointense, again due to blood products.
CTA or postcontrast CT imaging may reveal one or more small areas of enhancement within a hematoma; this “spot sign” is thought to represent
ongoing bleeding. T e presence of a spot sign is associated with an increased risk of hematoma expansion, increased mortality, and lower likelihood of favorable functional outcome. Some centers routinely perform CT with CTA and postcontrast CT at the time oF initial imaging to rapidly identify any macrovascular etiology
of the hemorrhage and provide prognostic information
at the same time.
The condition of patients with ICH frequently deteriorates within the first 24 or 48 hours after symptom onset because of secondary injuries caused by hematoma expansion, intraventricular hemorrhage (IVH) extension, fever, and high blood pressure . Hence, patients in the acute phase of ICH should be monitored and taken care of in facilities in which the close monitoring of the patient’s status and frequent administration of medications are possible.
Based on the viewpoint that increased BP causes greater tearing of blood vessels and flow-out of blood through these vessels and eventually leads to the expansion of the hematoma, high BP is considered to be associated with hematoma expansion and poor outcomes, especially early neurological deterioration, mortality, and dependency. Thus, intensive BP reduction is thought to reduce hematoma expansion and improve the clinical outcomes in patients with ICH.
Nonvasodilating IV drugs such as nicardipine,labetalol or esmolol
As the optimal timing for resumption of anticoagulation after anticoagulation-related ICH is unknown, the risk of both cardioembolic events and recurrent anticoagulation-related ICH should be considered together in determining the starting time of anticoagulation. In general, resumption of VKA within the first month is associated with a high risk of recurrent ICH . Therefore, a delay of at least 1 month should be suggested in patients with VKA-related ICH . However, early resumption of anticoagulation may be needed in patients with prosthetic heart valves because of the high risk of cardioembolic events.In patients with lobar ICH, resumption of anticoagulation is reported to be associated with higher risk of recurrent ICH compared with deep hemispheric hemorrhage (1-year risk of recurrence, 15% versus 2.1%) . Therefore, avoidance of long-term anticoagulation with VKA as a treatment for nonvalvular atrial fibrillation is probably recommended in patients with VKA-associated lobar ICH. The safety of antiplatelet agents as alternatives to VKA in patients with lobar ICH is controversial . In patients with non-lobar ICH, antiplatelet monotherapy can be a safer alternative to VKA in some patients with atrial fibrillation . As alternatives to VKA after ICH, the usefulness of NOACs including dabigatran, rivaroxaban, and apixaban, remains unknown.
The effect of antiplatelet drugs on the outcome of ICH is uncertain. Two observational studies showed that reduced platelet activity is associated with IVH, death, early ICH growth, and poor functional outcome. Another study reported that the use of antiplatelet medication at the onset of ICH symptoms was not associated with increased hemorrhage volume, hematoma expansion, or poor functional outcome
rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not recommended for VKA reversal in ICH (Class III; Level of Evidence C).
Intracranial hypertension following ICH is common, especially in younger patients with supratentorial hemorrhage [67]. The most common causes of intracranial hypertension are hydrocephalus from IVH and surrounding edema from hematoma.
Methods for the medical management of ICP consist of head elevation to 30°, hyperventilation, mild sedation, and hyperosmolar therapy with hypertonic saline or mannitol. Mannitol can be administered intravenously, but special attention should be paid to volume depletion.
Studies using continuous electroencephalography (EEG) showed that electrographic seizures occurred in up to one third of the patients with ICH . Clinical seizures are as frequent as 16% within 1 week after ICH and the location of the hematoma influences this frequency; cortical involvement is a crucial risk factor of early seizures .
For cerebellar hemorrhages, a neurosurgeon should be consulted immediately to assist with the evaluation; most cerebellar
hematomas >3 cm in diameter will require surgical evacuation. If the patient is alert without focal brainstem signs and if the hematoma is <1 cm in diameter, surgical removal is usually unnecessary. Patients with hematomas between 1 and 3 cm require careful observation for signs of impaired consciousness, progressive hydrocephalus, and precipitous respiratory failure. Hydrocephalus due to cerebellar hematoma should not be treated solely with ventricular drainage. As hematoma evacuation of a brainstem hemorrhage may be harmful in many cases, brainstem hemorrhage is usually managed conservatively
The frequency of medical complications after acute stroke is high, although there is substantially more information reported for ischemic stroke than ICH. comprehensive screening, monitoring, and appropriate care for each medical complication should accompany the standard management regime for ICH.
all patients with an Intracerebral Hemorrhage Score of 0 survived, and all of those with a score of 5 died; 30-day mortality increased steadily with the Score
