Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes and affects ~65,000 patients annually in the US. Mortality ranges from 35-52% and only 20% are functionally independent at six months.
Once the diagnosis has been made, the emergency provider should focus on preventing hematoma expansion, optimizing cerebral perfusion and ensuring the best environment for recovery.
Here are the Cliff Notes to Dr. Siket’s Lecture Below
The ‘CTA Spot Sign’ is one predictor of early expansion and poor outcome.
Warfarin and novel oral anticoagulant associated ICH should be reversed early and aggressively.
Reversing antiplatelet medications is not recommended.
Surgery is indicated for most cerebellar ICH.
Intraventricular hemorrhage and hydrocephalus should be treated with placement of an external ventricular drain.
Aggressive BP lowering is safe, but has not been shown to be beneficial.
Close management of glucose, temperature, and dysphagia impacts survival.
Routine seizure prophylaxis is not supported by evidence.
In severe ICH it is reasonable to trial aggressive medical management for 1-2 days in accordance with family wishes.
Matthew S. Siket, MD, MS
Assistant Professor of Emergency Medicine
Warren Alpert Medical School of Brown University
Broderick J et al. Circulation 2007
Brott et al. Stroke 1997
Brouwers HB et al. JAMA Neurol 2014
Steiner T. et al, Lancet Neurology April 2016
Pollack et al, NEJM 2015
Miller L et al. J Emerg Med 2016
Connolly, SJ et al, NEJM 2016
Baharoglu MI et al. Lancet 2016
Prodan CI. Lancet 2016
Mendelow et al. Lancet 2005
Mendelow et al. Lancet 2013
Naff N, et al. Stroke 2011
De Oliveira Manoel et al. Critical Care 2016
Hemphill JC et al. Stroke 2015
Balami JS Buchan AM Lancet Neurol 2012
Elliott J Smith M. Anesth Analg 2010
Kate MP et al. J Cereb Blood Flow Met 2014
C. S. Anderson et al. NEJM 2013
AI Qureshi et al, NEJM 2016
Kuramatsu JB et al. JAMA 2015
Middleton et al. Lancet Neurology 2011
Frontera JA et al. Neurocrit Care 2016
Messe SR et al. Neurocrit Care 2009
Naidech AM et al. Stroke 2009