Spontaneous
Intracerebral Hemorrhage
Tracy Wheeler, AGACNP-BC
Advanced Spine and Brain Center
Objectives
Etiology
Initial management, prehospital and ED including imaging
Treatment including management of hypertension, reversal of AC,
avoidance of secondary injury, and importance of nursing cares
Management of intracranial hypertension
Rehab
Case Study
What is nontraumatic spontaneous
intracranial hemorrhage
Blood accumulation within the brain parenchyma
Second leading type of stroke
Global burden is higher than ischemic (death and disability)
Several etiologies, including hypertension, cerebral amyloid angiopathy,
and vascular causes
Etiologies
Hypertension (arteriolosclerosis)
Cerebral amyloid angiopathy
Vascular- AVM, DAV, Aneurysm
Others- hemorrhagic infarct, tumor,
sepsis, moyamoya, etc..
(Greenberg et al., 2022) (Hemphill et al., 2015)
Hypertension
Most common cause
Hypertensive- typically associated with the blood vessels which feed off the
major cerebral arteries (90 angle)- feeding pons, midbrain, and thalamus
Cerebral Amyloid Angiopathy
older patients with lobar hemorrhage
CAA- amyloid tissue deposits on vessel wall and weakens the vessel
Can distinguish CAA vs hypertensive in older person by location
Signs and Symptoms of ICH
Impossible to determine hemorrhagic vs ischemic (without imaging)
Based on size and location
Symptoms typically associated with ICH (rapidly progressing)
Vomiting
SBP >220
Severe headache
Coma, decreased LOC
Prehospital management
Very important- 20% decline in the time between EMS and ED evaluation
Early treatment improve long term outcomes
Primary goal- Airway management, CV support, and transport
Secondary goal- focused history including timeline, medical history, and
medication history
Notify hospital in advance
(Greenberg et al., 2022) (Hemphill et al., 2015)
Evaluation
History
Time and characteristics of symptoms
Risk factors?
Meds
Recent surgery/trauma
Illicit drugs
Liver disease
Kidney disease
Diabetes
Evaluation
P/E
VS
Neurological exam- NIHSS, NIHf,
GCS
Baseline severity score (ICH score)
Severity Score- ICH score
Communication tool and grading scale to evaluate for 30 day mortality
GCS
ICH Volume
IVH
Location
Age
Evaluation
Labs
COAGS
CBC
Kidney function tests
Glucose
Cardiac markers
UA/culture
(Greenberg et al., 2022) (Hemphill et al., 2015)
Imaging
CT head wo- gold standard (quick, high sensitivity)
MRI
CTA, MRA- evaluate for vascular cause, (Rordorf & McDonald, 2022)
spot sign with increased risk of HE and worsening outcomes
Aneurysm
AVM
Catheter angiogram if high suspicion for vascular cause
(Greenberg et al., 2022) (Hemphill et al., 2015)
Treatment
Treat hypertension
Reverse coagulopathy
Prevent hematoma expansion and secondary brain injury or
complications
Corrected INR and SBP < 160 within 4 hours has shown reduced
rates of hematoma expansion (Hemphill et al., 2015)
BP management
VERY IMPORTANT to improve outcomes and reduces hematoma
expansion!
Presenting SBP 150-220, safe to lower to SBP 130-140 (<130 can be harmful)
(Greenberg et al., 2022)
Smooth reduction of BP- Nicardipine infusion
It is safe to reduce SBP to 140 in patients who presented with SBP 150-220
(Class IA evidence) (Interact2 study)- improved outcomes and QOL
(Hemphill et al., 2015)
Reversal of AC
Warfarin- vitamin K, 4 factor PCC (kcentra), FFP
For warfarin induced: Kcentra and Vit K d/t transient nature of PCC
Pradaxa- Praxbind, PCC, HD (if praxbind not available)
Xarelto, Eliquis – Andexxa, Kcentra ( 4 factor activated PCC)- ongoing
studies
Heparin- Protamine
Plavix- DDAVP (Don’t give platelets unless going to surgery- 1 unit, PATCH
trial)
(Greenberg et al., 2022) (Rordorf & McDonald, 2022)
Preventing secondary injury &
hematoma expansion
Hematoma expansion occurs in up 1/3 of ICH- poor function outcome
HE independent predictor of poor outcomes (Rordorf & McDonald, 2022)
Increased glucose Increased mortality and poor outcomes
Avoid hyper and hypo-glycemia
Treat fever (prolonged fever leads to worse outcomes, could relate to hematoma growth)
r/o infectious causes
Seizure
Treat if patient has a seizure
Altered mental status + EEG findings- AED
Decreased MS out of proportion- continuous EEG
No prophylactic AED
(Hemphill et al., 2015)
DVT prophylaxis
SCD (compression stockings are not adequate)
Early mobility
After documented stable CT, may start SQ heparin or Lovenox on PBD 1-4
Known symptomatic DVT/PE- heparin gtt vs IVC filter
(Hemphill et al., 2015)
Medical complications
Pneumonia
Aspiration
Respiratory failure
PE
Sepsis
Heart failure- MI, stress induced cardiomyopathy, etc
Formal dysphagia screen
ECG and cardiac markers after I CH
50 % of deaths after stroke attributed to these medical complications, with increase mortality
(Hemphill et al., 2015)
Nursing Care
ICU
Frequent monitoring and exams
Protocols for treatment of ICP, BP, fever, and glucose
Positioning, early mobilization, and oral care
Nurses care for ICH should be trained in GCS, NIHSS
DNR
Discuss after 2nd full hospital day
Self fulfilling prophecy
Unless patient already has DNR status, and this should not decrease
medical cares
Reiterated in the recent 2022
guidelines
(Hemphill et al., 2015)
ICP
Monroe Kelly Doctrine
Brain parenchyma (80%), CSF (10%), Blood (10%)in a rigid compartment.
Increase in 1 component must have a decease in the another.
Body will compensate for a period of time, then ICP will rise (Blood, CSF, or
brain will discplace)
Normal ICP 5-15, >20 elevated
CPP= MAP - ICP
S/S elevated ICP
Mental status change
N/V/Headache
Noted on bedside monitor
Pupillary changes
Posturing
Cushings triad
Treatment for ICP
Nursing cares, VERY IMPORTANT
Elevate HOB
Neck straight alignment
Check cervical collar
Reduce pain/anxiety
Prevent shivering
Treat fever
Neurosurgical intervention
Mannitol, Hypertonic saline
ICP monitor: EVD vs Bolt
Decompressive craniectomy
When to measure ICP
EVD for treatment of hydrocephalus
With decreased LOC (IIA evidence)
GCS < 8
Herniation
Patients with intraventricular
hemorrhage may benefit from
intraventricular TPA. (Greenberg et al., 2022)
Surgery- When to operate
Hemorrhage removal is a life saving procedure.
Generally not found to improve
long-term functional outcomes
For supratentorial hemorrhage-
For nontraumatic- not generally recommended
STICH I- Will surgery improv e mortality and functional outcomes?
STITCH II- What if it’s superficial?
STITCH I, STITCH II, and MISTIE- no clear data that outcomes improv e with surgery, can
be considered “life sav ing”
DC – again, not well studied
(Greenberg et al., 2022)
Surgery- When to operate
Posterior Fossa
> 15cc (Greenberg et al., 2022)
Worsening neuro exam
Hydrocephalus from obstruction
Brainstem compression
Prevention of Recurrent ICH
Review patient specific risk factors
SBP < 130/80- modify BP immediately after bleed (Selim, 2022)
Etoh < 2 drinks/day, no illicit drugs, tobacco use
Treat OSA
Resume AC uncertain, wait 4-8 weeks in patients w/o mechanical heart
valves. Aspirin can be started following days, IF needed. Antiplatelet w/
valve may be started after stable CT head. (Selim, 2022)
Rehab
Multidisciplinary rehab
Reasonable to start within 24-48, NOT first 24 hours
Continue rehab into a community program
Monitor closely for depression (Greenberg et al., 2022)
Case Study
49-year-old male presented via EMS after being found down by his wife
PMH: hypertension- untreated, no PCP
Meds: No prescription medications, multiple supplements and diet pills
Initial presentation- Obtunded, moving the left arm and leg spontaneously,
densely plegic on the right. Sonorous respirations with apnea.
Case Study: Evaluation
Exam: VS: BP 214/131. Initial NIHSS 25, GCS 8. Densley plegic on left.
Labs (p): INR 1.1
CT: large left basal ganglia ICH measuring 6.3 cm x 2.6 cm, significant
mass-effect and effacement of the left lateral ventricle, 1 cm left on right.
ICH score: 2 - estimated 30 day mortality of 26%
Case Study: Evaluation
Case Study: Treatment
Cardene infusion to keep SBP <140
Intubated for airway protection
Taken emergently to the OR for decompressive craniectomy
Case Study: ICU care
Hourly neuro checks
Hypertonic saline, sodium goal 145-150
Cardene infusion for SBP <140
Oral Norvasc initiated
POD 2- extubated
Exam- Aphasic, facial droop, densely plegic on right
Complication with external hydrocephalus required an LP shunt
Ultimately dc’d to rehab.
6 month follow up- remained densely plegic, but at home and remaining
mobile with wheelchair
References
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