DESCRIPTION 
Hemorrhage into brain parenchyma:
- Compression of brain tissues
- Secondary injury results from:
- Cerebral edema
- Increased intracranial pressure (ICP)
- Potential of brain herniation
ETIOLOGY
Intracerebral hemorrhage can occur spontaneously or from trauma:
- Uncontrolled or acute HTN (most common)
- Vascular malformations:
- Neoplasm (particularly melanoma and glioma)
- Anticoagulant therapy (warfarin, heparin)
- Thrombolytic agents
- Illicit drugs (cocaine, amphetamines)
- Bleeding disorders (hemophilia)
- Cerebral amyloid angiopathy
- Traumatic hemorrhage secondary to blunt or penetrating injury
[Outline]
SIGNS AND SYMPTOMS
History
- Severe headache, typically sudden in onset
- Seizure
- Evidence of head injury
- Neck stiffness
- Vomiting
- Anticoagulation therapy
- Altered level of consciousness (may be comatose):
Physical Exam
- HTN
- Nuchal rigidity
- Altered mental status
- Variable neurologic deficits depending on site of intracerebral hemorrhage:
ESSENTIAL WORKUP
- Manage airway if indicated
- Immediate noncontrast head CT:
- Acute hemorrhage appears as high-density lesion
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC
- Coagulation studies (PT/PTT, INR, platelets)
- Electrolytes; BUN, creatinine
- Pregnancy test in women of childbearing age
- EKG
- Consider toxicology screen
Imaging
- CT as above
- MRI may be useful but currently not as available or rapid as CT
Diagnostic Procedures/Surgery
- CT angiography:
- Gaining increasing acceptance as a diagnostic tool in acute setting
- Up to 15% of patients may show an underlying vascular etiology on CTA, potentially changing acute management
- Contrast extravasation (spot sign) may represent ongoing bleeding
- Highest risk of hematoma expansion with poor outcome and mortality
DIFFERENTIAL DIAGNOSIS
Pediatric Considerations
Additional differential diagnoses include:
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PRE-HOSPITAL
- C-spine precautions if head or neck injury is suspected
- Elevation of head with C-spine control
- Initial pre-hospital responder must ascertain neurologic defect to be able to note progression of symptoms
INITIAL STABILIZATION/THERAPY
- Manage airway and resuscitate as needed:
- Patients with depressed level of consciousness should be intubated immediately for controlled ventilation
- Early neurosurgical consultation
ED TREATMENT/PROCEDURES
- Prompt neurosurgery and/or neurology consultation
- BP management:
- Must use caution in BP control because acute lowering of BP to normal in setting of increased ICP could reduce cerebral perfusion to ischemic levels
- Use labetalol, nicardipine, esmolol, enalapril to lower diastolic BP initially by 10%
- Normotensive levels should be achieved over 12–24 hr
- May use nitroprusside, nitroglycerin, or hydralazine as an alternative
- Treatment of elevated ICP:
- Controlled ventilation to PaCO2 of 35 Torr
- Fluid restriction; elevate head of bed 30°
- Mannitol—osmotic diuresis
- Use furosemide as an alternative
- Correct coagulopathies:
- Consider fresh frozen plasma (FFP), platelets, prothrombin complex concentrates, vitamin K
- Consider anticonvulsants
MEDICATION
- Esmolol: 0.5–1 mg/kg initial bolus IV, followed by 50–150 µg/kg/min infusion
- Enalapril: 1.25–5 mg q6h (risk of precipitous BP lowering, test dose 0.625 mg)
- FFP: 10–20 mL/kg IV
- Fosphenytoin: 15–20 mg/kg phenytoin equivalents (PE) at rate of 100–150 mg/min IV/IM
- Furosemide: 20–40 mg (peds: 0.5–1 mg/kg/dose) IV; may repeat as necessary
- Hydralazine: 10–40 mg (peds: 0.1–0.2 mg/kg/dose; max. 20 mg/dose) IV; may repeat as necessary
- Labetalol: 20 mg (peds: 0.3–1 mg/kg/dose; max. 20 mg/dose) IV; may give additional 40–80 mg IV q10min to max. 300 mg
- Mannitol: 1 g/kg IV
- Nicardipine: 5–15 mg/h infusion
- Nitroprusside: Start 0.25–10 µg/kg/min IV (max. 10 µg/kg/min); titrate to effect
- Phenytoin: 15–20 mg/kg/dose (peds: 15 mg/kg) at rate of < 40–50 mg/min
- Platelet: 1–2 U IV in consultation with neurosurgery
- Prothrombin complex concentrates: 500–1,000 IU IV
- Vitamin K: 5–10mg IV over 30 min
[Outline]
DISPOSITION
Admission Criteria
- To OR if surgical intervention is indicated
- To ICU if intubated, altered level of consciousness, or on IV infusion for BP control
- Admit to neurologic observation unit if normal neurologic exam without evidence of progression of bleed and hemodynamically stable
Discharge Criteria
All patients with intracerebral hemorrhage should be admitted
Issues for Referral
Rehabilitation is a key aspect of recovery
FOLLOW-UP RECOMMENDATIONS
- Treating HTN in the nonacute setting is the most important step to reduce the risk of intracerebral hemorrhage
- Discontinuation of smoking, alcohol use, and cocaine use prevents recurrence of intracerebral hemorrhage
[Outline]
- Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: A guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38:2001–2023.
- Caceres JA, Goldstein JN. Intracranial hemorrhage. Emerg Med Clin North Am. 2012;30:771–794.
- Naval NS, Nyguist PA, Carhuapoma JR. Management of spontaneous intracerebral hemorrhage. Neurol Clin. 2008;26:373–384.
- Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59:460–468.
- Nishijima DK, Offerman SR, Ballard DW, et al. Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. Acad Emerg Med. 2013;20:140–145.
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