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.
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)
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]
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)
- 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)
- 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)