Intracerebral hemorrhage early assessment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Intracerebral hemorrhage (ICH) is a medical emergency. Rapid diagnosis and management is crucial because early deterioration is common in the first few hours after ICH onset.^[1]

Early assessment

Prehospital Management

Prehospital Management may include:^[1]

Provide ventilatory support
Provide cardiovascular support
Transport the patient to the closest facility
- Plan for rapid transfer to a tertiary care center with crucial resources (such as neurology, neuroradiology, neurosurgery, and critical care facilities)

Emergent management

Many centers have critical pathways developed for the treatment of acute ischemic stroke. However, few have protocols for the management of intracranial hemorrhage (ICH).

Emergent management may include:^[2]
- Neurosurgical interventions for hematoma evacuation, external ventricular drainage or invasive monitoring and treatment of ICP
- Blood pressure management
- Intubation
- Reversal of coagulopathy

General Monitoring

Patients with ICH are frequently medically and neurologically unstable, particularly within the first few days after onset. Care of ICH patients in a dedicated neuroscience intensive care unit (dedicated stroke unit) rather than an intensive care unit General monitoring includes:^[3]^[4]

Frequent vital sign checks
Neurological assessments
Continuous cardiopulmonary monitoring (cycled automated BP cuff, electrocardiographic telemetry, and pulse oximetry)
Continuous intra-arterial BP monitoring (in patients receiving intravenous vasoactive medications)

References

↑ ^1.0 ^1.1 Moon JS, Janjua N, Ahmed S, Kirmani JF, Harris-Lane P, Jacob M; et al. (2008). “Prehospital neurologic deterioration in patients with intracerebral hemorrhage”. Crit Care Med. 36 (1): 172–5. doi:10.1097/01.CCM.0000297876.62464.6B. PMID 18007267.
↑ Cooper D, Jauch E, Flaherty ML (2007). “Critical pathways for the management of stroke and intracerebral hemorrhage: a survey of US hospitals”. Crit Pathw Cardiol. 6 (1): 18–23. doi:10.1097/01.hpc.0000256146.81644.59. PMID 17667882.
↑ Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355– 2365. doi: 10.1056/NEJMoa1214609.
↑ Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intrace- rebral hemorrhage. Crit Care Med. 2001;29:635–640.

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[pmid18007267-1] 1.0 ^1.1 Moon JS, Janjua N, Ahmed S, Kirmani JF, Harris-Lane P, Jacob M; et al. (2008). “Prehospital neurologic deterioration in patients with intracerebral hemorrhage”. Crit Care Med. 36 (1): 172–5. doi:10.1097/01.CCM.0000297876.62464.6B. PMID 18007267.

[pmid17667882-2] Cooper D, Jauch E, Flaherty ML (2007). “Critical pathways for the management of stroke and intracerebral hemorrhage: a survey of US hospitals”. Crit Pathw Cardiol. 6 (1): 18–23. doi:10.1097/01.hpc.0000256146.81644.59. PMID 17667882.

[Anderson-3] Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355– 2365. doi: 10.1056/NEJMoa1214609.

[Diringer-4] Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intrace- rebral hemorrhage. Crit Care Med. 2001;29:635–640.

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