Intracerebral hemorrhage occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain. (The name means within the.
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- Management of intracerebral hemorrhage
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- Intracerebral hemorrhage: Symptoms, risk factors, and treatment
- What causes it?.
- What is an intracerebral hemorrhage?.
- The Internet Stroke Center.
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Antifibrinolytic agents such as e-aminocaproic, tranexemic acid, aprotinin, and activated recombinant Factor VII rFVIIa have been receiving attention for early hemostatic therapy in patients with no underlying coagulopathy. The Novoseven Phase II trial was an international, multicenter, double-blinded trial that clearly demonstrated a reduction in early hematoma expansion in patients administered rFVIIa within 4 hours of symptom onset compared with placebo. In fact, the hemostatic effect was more pronounced with incremental doses of rFVIIa Mayer et al This problem can be exacerbated by intraventricular hemorrhage, which leads to acute obstructive hydrocephalus.
When ICP is monitored, use of a standard management algorithm results in better control, fewer interventions, and shorter duration of therapy. Initially, acute and sustained increase in ICP should prompt a repeat CT to assess the need for a definitive neurosurgical procedure. An intravenous sedative such as propofol 0. If ICP does not respond to sedation and cerebral perfusion management, osmotic agents and hyperventilation should be considered Mckinley et al Of the 3 osmotic agents frequently used mannitol, glycerol, and sorbitol , each has characteristic advantages and disadvantages.
Sorbitol and glycerol are metabolized by the liver and interfere with glucose metabolism. However, sorbitol is infrequently used due to a short half life and poor penetration into the cerebrospinal fluid CSF. Glycerol has a half-life less than one hour but it penetrates into the cerebrospinal fluid the best. Mannitol is commonly used because it is renally metabolized, has a half-life up to 4 hours, and achieves intermediate concentrations within the CSF Nau Large ICH associated with elevated intracranial pressure refractory to these measures is fatal in most patients but a barbiturate coma may considered as a last resort to try to reduce intracranial pressure Broderick et al ; Mckinley et al Corticosteroids are not recommended in the management of ICH because they have been proven to offer no benefit in randomized trials Tellez and Bauer ; Poungvarin et al Ventricular drains should be used in patients with or at risk for hydrocephalus.
Drainage can be initiated and terminated according to clinical performance and ICP values. The volume of IVH strongly affects morbidity and mortality at days Tuhrim et al Preliminary studies with urokinase have suggested use of intraventricular thrombolysis within 72 hours of IVH may help drain the blood filled ventricles, speed clot resolution and decrease day mortality rate Naff et al ; Naff et al Patients are currently being recruited for Phase III trials assessing thrombolytic use in intraparenchymal and intraventricular hemorrhage.
Seizures most commonly occur at the onset of hemorrhage and may even be the presenting symptom. Lobar location is an independent predictor of early seizures Passero et al Although, no randomised trial has addressed the efficacy of prophylactic antiepileptic in ICH patients, the Stroke Council of the American Heart Association suggest prophylactic antiepileptic treatment may be considered for 1 month in patients with intracerebral hemorrhage and discontinued if no seizures are noted Broderick et al ; Temkin Acute management of seizures entail administering intravenous lorazepam 0.
Fever after ICH is common and should be treated aggressively because it is independently associated with a poor outcome Schwarcz et al Sustained fever in excess of Patients should be physically examined and should undergo laboratory testing or imaging to determine the source of infection. Fever of neurologic origin is diagnosis of exclusion and may be seen when blood extends into the subarachnoid or intraventricular Commichau and Scarmeas Intracerebral hemorrhage patients with persistent fever that is refractory to acetaminophen and without infectious cause may require cooling devices to become normothermic.
Adhesive surface-cooling systems and endovascular heat-exchange catheters are better at maintaining normothermia than conventional treatment. However, it is still unclear whether maintaining normothermia will improve clinical outcome Dringer Immobilized state due to limb paresis predisposes ICH patients for deep vein thrombosis and pulmonary embolism.
Intermittent pneumatic compression devices and elastic stockings should be placed on admission Lacut et al A small prospective trial by Boeer and colleagues using low-dose heparin on hospital day 2 to prevent thromboebolic complications in ICH patients significantly lowered the incidence of pulmonary embolism and no increase in rebleeding was observed Boeer et al Numerous surgical trials since the s offered conflicting results and until recently no firm conclusions could be reached regarding the operative management of intracerebral hemorrhage.
This trial was an international, multicenter trial that randomized patients with spontaneous supratentorial intracerebral hemorrhage within twenty-four hours to early surgery or conservative best medical therapy. Size, location, and volume of hemorrhage were similar in both treatment groups.
Management of intracerebral hemorrhage
Patients randomized to early surgery had their hematoma evacuated within twenty-four hours of randomization by the method of choice of the designated neurosurgeon. Structured postal questionnaires were used to assess outcomes with the Glasgow Coma Scale, modified Rankin Scale, Barthel index, and mortality at 6-months. Overall, the STICH trial revealed no benefit from early craniotomy in supratentorial intracerebral hemorrhage when compared to initial conservative management.
Of the prespecified subgroups that were examined, patients with an ICH within a centimeter of the cortical surface showed a benefit for early surgery. However, the statistical testing of this subgroup was not adjusted for in the multiple subgroup comparisons in this trial. In addition, early surgery was delayed with median time from onset to treatment for early surgery group was 30 hours and that may have affected the outcome Broderick ; Mendelow et al In contrast, infratentorial hemorrhages seem to benefit from early surgery.
Most neurosurgeons believe cerebellar hemorrhages greater than 3 centimeters benefit from early surgical intervention because of the significant risk of brainstem compression and obstructive hydrocephalus within 24 hours Ott et al New areas of surgical research are focused on combination of minimally invasive surgery and and clot lysis with r-tPA to remove intracerebral hemorrhage.
Small preliminary trials have demonstrated that stereotactic aspiration and thrombolysis spontaneous intracerebral hemorrhage appears to be safe and effective in the reduction of ICH volume Teernstra et al ; Barrett et al ; Vespa et al Currently, no specific therapies improve the outcome after ICH. New trials evaluating the safety of the combination of minimally invasive surgery and clot lysis with r-tPA to remove intracerebral hemorrhage are currently underway.
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Abstract Currently, intracerebral hemorrhage ICH has the highest mortality rate of all stroke subtypes Counsell et al ; Qureshi et al Open in a separate window. CT scan showing hemorrhage in the left thalamus secondary to hypertension. Clinical presentation The classic presentation of ICH is sudden onset of a focal neurological deficit that progresses over minutes to hours with accompanying headache, nausea, vomiting, decreased consciousness, and elevated blood pressure. Management Emergency management ICH is a neurological emergency and initial management should be focused on assessing the patients airway, breathing capability, blood pressure and signs of increased intracranial pressure.
Early hemostatic therapy In the past, early neurologic deterioration in ICH was attributed to edema and mass effect around the hematoma. Fever control Fever after ICH is common and should be treated aggressively because it is independently associated with a poor outcome Schwarcz et al Deep venous thrombosis prophylaxis Immobilized state due to limb paresis predisposes ICH patients for deep vein thrombosis and pulmonary embolism.
Surgical management Numerous surgical trials since the s offered conflicting results and until recently no firm conclusions could be reached regarding the operative management of intracerebral hemorrhage. Conclusion Currently, no specific therapies improve the outcome after ICH. Guidelines for thrombolytic therapy for acute stroke: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association.
An evidence-based approach to management of increased intracranial pressure. A systematic review of the frequency and prognosis of the arteriovenous malformation of the brain in adults. Can J Neurol Sci. Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage. Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage.
Early heparin therapy in patients with spontaneous intracerebral haemorrhage. J Neurol Neurosurg Psychiatry. Guidelines for the management of spontaneous intracerebral hemorrhage: Early hemorrhage growth in patients with intracerebral hemorrhage. Fenestrations in the internal elastic lamina at bifurcations of human cerebral arteries. Causes and predictors of death in cerebral venous thrombosis. Risk factors for fever in the neurologic intensive care unit.
Primary intracerebral hemorrhage in the Oxfordshire Community Stroke Project. Dandapani BK, Suzuki S, et al. Relation of blood pressure and outcome in intracerebral hemorrhage. Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: Pathological observations in hypertensive cerebral hemorrhage.
J Neuropathol Exp Neurol. Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Accessed 11 Apr Fredriksson K, Norrving B, et al. Emergency reversal of anticoagulation after intracerebral hemorrhage. Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage. Headache in acute cerebrovascular disease. Angiography in non-traumatic brain haematoma. An analysis of cases. A Prospective evaluation of cerebral angiography and computed tomography in cerebral haematoma.
Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: The bleeding risk in chronic haemodialysis: Enlargement of spontaneous intracerebral hemorrhage. Incidence and time course. The natural history of cerebral cavernous malformations. Significance of hemorrhage into brain tumors: Prevention of venous thrombosis in patients with acute intracerebral hemorrhage. Blood pressure and clinical outcomes in the International Stroke Trial. Emergency oral anticoagulant reversal: Ultra-early Hemoastatic therapy for primary intracerebral hemmorhage: Recombinant activated factor VII for acute intracerebral hemorrhage.
Clinical trial of an air-circulating cooling blanket for fever control in critically ill neurologic patients. Perilesional blood flow and edema formation in acute intracerebral hemorrhage. Standardized management of intracranial pressure: Advancing age and hypertension are the most important risk factors for ICH. When a person is brought to the emergency room with a suspected brain hemorrhage, doctors will learn as much about his or her symptoms, current and previous medical problems, medications, and family history.
The person's condition is assessed quickly. Diagnostic tests will help determine the source of the bleeding. Computed Tomography CT scan is a noninvasive X-ray to review the anatomical structures within the brain and to detect any bleeding. CT angiography involves the injection of contrast into the blood stream to view arteries of the brain.
Angiogram is an invasive procedure, where a catheter is inserted into an artery and passed through the blood vessels to the brain. Once the catheter is in place, contrast dye is injected into the bloodstream and X-rays are taken. Magnetic resonance imaging MRI scan is a noninvasive test, which uses a magnetic field and radio-frequency waves to give a detailed view of the soft tissues of your brain. An MRA Magnetic Resonance Angiogram involves the injection of contrast into the bloodstream to examine the blood vessels as well as the structures of the brain.
Treatment may include lifesaving measures, symptom relief, and complication prevention. Once the cause and location of the bleeding is identified, medical or surgical treatment is performed to stop the bleeding, remove the clot, and relieve the pressure on the brain. Patients with large lobar hemorrhages 50 cm3 who are deteriorating usually undergo surgical removal of the hematoma. Medical treatment The patient will stay in the stroke unit or intensive care unit ICU for close monitoring and care.
Surgical treatment The goal of surgery is to remove as much of the blood clot as possible and stop the source of bleeding if it is from an identifiable cause such as an AVM or tumor. Depending on the location of the clot either a craniotomy or a stereotactic aspiration may be performed. Immediately after an ICH, the patient will stay in the intensive care unit ICU for several weeks where doctors and nurses watch them closely for signs of rebleeding, hydrocephalus, and other complications.
Once their condition is stable, the patient is transferred to a regular room. Some of these deficits may disappear over time with healing and therapy. The recovery process may take weeks, months, or years to understand the level of deficits incurred and regain function. Clinical trials are research studies in which new treatments—drugs, diagnostics, procedures, and other therapies—are tested in people to see if they are safe and effective.
Research is always being conducted to improve the standard of medical care.
Intracerebral hemorrhage: Symptoms, risk factors, and treatment
Information about current clinical trials, including eligibility, protocol, and locations, are found on the Web. Studies can be sponsored by the National Institutes of Health see clinicaltrials.
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