INTRACEREBRAL HEMORRHAGE

Management of intracerebral hemorrhage

Created 26/04/2021, last revision 29/04/2023

General therapy

The tabs below discuss specific issues regarding the conservative treatment of ICH.
Otherwise, the principles of general stroke therapy and intensive care, including intracranial hypertension management, apply.

Prognosis

assess the extent and characteristics of ICH on the baseline CT scan (ICH score, spot sign…)
- high ICH score is associated with a poor prognosis
- the spot sign predicts bleeding progression
asses neurological deficits, age, comorbidities, and biological condition
estimate ICH etiology (SMASH-U)
start intensive therapy for the first 24-48h, then consider whether to continue with full therapy or switch to DNR (AHA/ASA 2015 IIa/B)
- engage relatives in decision-making

Care setting

according to AHA/ASA guidelines 2022

provision of care in a specialized unit (e.g., stroke) with a multidisciplinary team providing the full range of high-acuity care and expertise is recommended
- for patients with clinical signs indicating evolving hydrocephalus, transfer to centers with neurosurgical capabilities for definitive hydrocephalus management (e.g., EVD placement and monitoring) is recommended
- it is reasonable to provide care in a neuro-specific ICU rather than a general ICU for patients with moderate-to-severe spontaneous ICH, IVH, hydrocephalus, or infratentorial bleeding
- for patients with IVH or infratentorial bleeding, transfer to centers with neurosurgical capabilities might be reasonable
using standardized protocols and/or order sets is recommended to reduce disability/mortality
frequent neurological assessments are reasonable for up to 72h of admission to detect early neurological deterioration

VTE prevention

→ prevention of VTE in stroke patients

start intermittent pneumatic compression (IPC) on the admission day, if possible (AHA/ASA 2022 1/B-R)
after bleeding has ceased and coagulation is normal, enoxaparin 0.4 mL SC 1-0-0 (low-dose LMWH) can be started 24-48 h from ICH onset (AHA/ASA 2022 2b/C-LD)
in patients with PE or acute deep vein thrombosis (DVT), consider retrievable IVC filter AHA/ASA 2022 2a/C-LD)
- a medical device that is temporarily implanted into the inferior vena cava (IVC) to prevent life-threatening pulmonary embolism in patients with contraindications to full anticoagulation
- delaying treatment with UFH or LMWH for 1-2 weeks after the onset of ICH might be considered (AHA/ASA 2022 2b/C-LD)
graduated compression stockings of knee-high or thigh-high length alone are not beneficial for VTE prophylaxis

Statins

do not discontinue statin therapy
- continuation of prior statin treatment appears to be safe
- patients already using statins have a better outcome and lower mortality [Flint, 2014]
do not start statin therapy in the acute phase of ICH – there is an increased risk of perihemorrhagic edema [Sprügel, 2021]
statins can be started later if needed

Intracranial hypertension

→ more about intracranial hypertension here

it is important to maintain intracranial pressure (ICP) and cerebral perfusion pressure (CPP) within normal ranges to reduce the risk of secondary brain injury
the head should be elevated to reduce ICP and maintain sufficient CPP (15-45°) – reverse Trendelenburg position
sedation
indication for ICP monitoring in ICH is ambiguous
- consider in patients with GCS ≤ 8 with extensive hematoma, intraventricular bleeding, or hydrocephalus (AHA/ASA 2022 IIb/B-NR)
if ICP is monitored, start treatment at ICP 20-25 mmHg
- target ICP < 20mm Hg, target CPP 50-70mmHg
- bolus hyperosmolar therapy ( MANNITOL or hypertonic saline) → more here
the efficacy of early prophylactic hyperosmolar therapy for improving outcomes is not well established (AHA/ASA 2022 2b/B-NR)
corticosteroids should not be administered! (AHA/ASA 2022 III/B-R)

AED

it is not recommended to administer AEDs prophylactically (even with lobar hematomas, which are associated with a greater risk of seizures). (AHA/ASA 2022 3/B-NR)
patients with seizures should be treated with antiepileptic drugs to reduce their morbidity → follow protocol for the treatment of symptomatic seizures (AHA/ASA 2022 1/C-LD)
in patients with unexplained abnormal or fluctuating mental status or suspicion of seizures, continuous EEG monitoring (≥24 hours) is reasonable to diagnose electrographic seizures and epileptiform discharges (AHA/ASA 2022 2a/C-LD)

Physiotherapy

start early (approx. from the 2nd day) in a hemodynamically stable patient
focus on support of circulatory and respiratory functions and prevention of deep vein thrombosis and pressure ulcers (bed sores)

Blood pressure management in the acute stage

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the 1st line IV drugs are:
- urapidil (EBRANTIL)
- enalapril (ENAP)
- labetalol (TRANDATE)
if they fail, try nitrates – isosorbide dinitrate (ISOKET)

start peroral medication as soon as possible (e.g., via NG tube if necessary) and gradually reduce/withdraw parenteral medication

Correction of hemostasis disorders

early detection and urgent correction of coagulation disorders is a key procedure in ICH therapy
antifibrinolytic drugs are not recommended except for thrombolysis-related bleeding

Patients with normal coagulation parameters

the FAST trial with recombinant f.VII (NOVOSEVEN) failed to show a reduction in mortality and disability. Mayer, 2008]
- reduced growth of the hematoma was counteracted by an increased risk of thromboembolic complications (especially in cohort with 80 μg dose) (AHA/ASA 2010 class III, LoE A)
similarly, the effect of etamsylate (DICYNONE) and tranexamic acid (EXACYL) was not proven
- negative TICH-2 and STOP-AUST trials
- negative meta-analysis of 4 RCTs – hemostatic therapy showed a marginally significant benefit in reducing hematoma expansion in high-risk patients (predicted by CT scan markers). However, no significant improvement in functional outcome or reduction of mortality was observed [Nie, 2021]
- in the TICH-2 trial, no benefit was present in the subgroup of patients with positive spot sign [Ovesen, 2021]

Intracerebral hemorrhage in thrombocytopenia and thrombocytopathy

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Hemorrhagic infarction, thrombolysis-related bleeding

→ bleeding complications during thrombolysis

usually a consequence of late reperfusion with blood extravasation into the infarcted tissue (0.6-5%)
risk factors:
- early anticoagulation (therefore not recommended)
- thrombolysis (symptomatic IC bleeding ~ 6%)
- extensive infarction
- large artery occlusion with late recanalization
- not well-controlled hypertension and hyperglycemia
clinical manifestation depends on the extent of bleeding (ECASS classification)

Bleeding classification after Stroke and Reperfusion Therapy (ECASS II)

Intracerebral hemorrhage during anticoagulation therapy

prolonged bleeding on anticoagulant therapy is present in about 36-54% of patients (warfarin > DOAC) ⇒ neutralizing the anticoagulant effect is thus essential [Steiner, 2017]

→ neutralization of the anticoagulant therapy

Surgical treatment

the aim of surgery is:
- to decrease ICP
- to reduce the secondary damage from edema
- to reduce the risk of herniation
- to eliminate a potential source of bleeding

Monitoring of intracranial pressure (ICP)

ICP sensor can be implanted after correction of coagulation parameters
indications are ambiguous
- patients with GCS ≤ 8 with extensive parenchymal hematoma, intraventricular hemorrhage with obstructive hydrocephalus (AHA/ASA 2015 IIb/C)
intraparenchymal or intraventricular sensor
- the intraventricular catheter is inserted through the brain into the lateral ventricle; it allows CSF drainage
main risks:
- bleeding – the type of the hemorrhage depends on the site of insertion (intraparenchymal, intraventricular, or subdural)
- infection (up to 12%, the risk is higher with intraventricular catheters) – CSF should be sent for cytology and culture analysis if the infection is suspected
leave sensor for a maximum of 5-7 days; later, the risk of infection increases, and the accuracy of the measurement decreases
ICP treatment according to cranial trauma protocols
- ⇒ target CPP 50-70 mmHg
- ⇒ target ICP < 20mmHg

External ventricular drainage (EVD)

used typically in massive intraventricular hemorrhage or expanding cerebellar hematomas with acute obstructive hydrocephalus (AHA/ASA 2022 I/B-NR)
- modern catheters allow concurrent ICP monitoring
- careful monitoring of consciousness and repeated CT scans are required

Hematoma evacuation

relieving the pressure of the hematoma on the surrounding tissue may reduce secondary damage; craniotomy is burdened with complications, including continued bleeding
the usefulness of surgery is unknown in most patients, and the indication for ICH evacuation remains controversial (AHA-ASA 2015 IIb/A)
- the STICH and STICH III trials did not show a benefit of surgery over conservative management (< 48h, lobar hematomas 10-100ml, no IVH)
urgent evacuation of ICH (< 4h) does not improve outcome and mortality and may additionally increase the risk of bleeding (AHA/ASA 2015 IIb/A)

Indications

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Surgical procedures

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Treatment of the source of bleeding

the source of bleeding is mostly found in atypically localized hematomas and younger patients without hypertension
acute management is indicated in aneurysms with a high risk of early rebleeding
acute management of other sources of bleeding follows the general indications for surgery:
- mostly expansive behavior of the hematoma, 30-60 ml, GCS > 8
- cerebellar hematoma compressing the brainstem (usually > 3 cm)
malformations are often complicated and require a multidisciplinary approach (a combination of endovascular, surgical, and radiation therapy)

Surgery in intraventricular hemorrhage (IVH)

treat the underlying cause of bleeding
detect and treat possible obstructive hydrocephalus (serial neurological status examinations and repeated CT scans are required for the diagnosis)
- external ventricular drainage (EVD) may be useful to reduce mortality, especially in patients with large ICH/IVH and impaired level of consciousness (LOC) (AHA/ASA 2022 1/B-NR)
  - for patients with a GCS score >3 and primary IVH or secondary IVH (with supratentorial ICH of <30-mL volume) requiring EVD, minimally invasive IVH evacuation with EVD plus thrombolytics is safe and is reasonable compared with EVD alone to reduce mortality (AHA/ASA 2022 2a/B-NR)
  - for patients with a GCS score >3 and primary IVH or secondary IVH (with supratentorial ICH of <30-mL volume) requiring EVD, the effectiveness of minimally invasive IVH evacuation with EVD plus the use of thrombolytics to improve functional outcomes is uncertain
  - for patients with large ICH/IVH and impaired LOC, the efficacy of EVD to improve functional outcome is not well established
- intraventricular application of tPA may facilitate and accelerate the evacuation of thrombus from the ventricles; it appears to be safe, but the clinical effect is unclear
  - CLEAR-IVH study – systemic bleeding 4%, ventriculitis 2%
  - CLEAR III trial – no substantial improvement in functional outcome at the mRS 3 cutoff compared to saline irrigation; mortality reduced by 10%
- alternative procedures include the endoscopic evacuation of the hematoma with ventriculostomy, VP shunt, or lumbar drainage – the benefit is unclear (AHA/ASA 2022 2b/C-LD)