Author:
AtulGupta
RebeccaSmith-Coggins
Description
Hemorrhage into brain parenchyma:
- Compression of brain tissue
- 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:
- Arteriovenous malformation
- Venous angiomas
- Ruptured cerebral aneurysms
- Neoplasm (particularly melanoma and glioma)
- Anticoagulant therapy
- Thrombolytic agents
- Illicit drugs (cocaine, amphetamines)
- Bleeding disorders (hemophilia)
- Cerebral amyloid angiopathy
- Traumatic hemorrhage secondary to blunt or penetrating injury
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):
- Altered mental status may occur as late as 24-48 hr after head injury
Physical Exam
- HTN
- Nuchal rigidity
- Altered mental status
- Variable neurologic deficits depending on site of intracerebral hemorrhage:
- Putamen hemorrhage (35%):
- Contralateral hemiparesis
- Contralateral hemisensory loss
- Occasional dysphagia
- Occasional neglect
- Lobar hemorrhage (30%):
- Variable signs depending on involved area
- Cerebellar hemorrhage (15%):
- Thalamic hemorrhage (10%):
- Similar to putamen, but may also have eye movement abnormalities
- Caudate hemorrhage (5%):
- Confusion
- Memory loss
- Hemiparesis
- Gaze paresis
- Pontine hemorrhage (5%):
- Quadriplegia
- Pinpoint pupils
- Ataxia
- Sensorimotor loss
Essential Workup
- Manage airway if indicated
- Immediate noncontrast head CT:
- Acute hemorrhage appears as high-density lesion
Diagnostic Tests & Interpretation
Lab
- CBC
- Coagulation studies (PT/PTT, INR, platelets)
- Electrolytes; BUN, creatinine
- Pregnancy test in women of childbearing age
- ECG
- 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
- Seizure:
- CNS infection
- CNS mass
- Electrolyte or acid-base abnormality
- Intoxication
- Wernicke encephalopathy
- Migraine headache
- Transient ischemic attack
- Nonhemorrhagic acute cerebrovascular accident
- Air embolism
- Differential diagnosis once bleed is seen on CT:
- Spontaneous hemorrhage:
- Hypertensive hemorrhage
- Arteriovenous malformation
- Neoplasm
- Traumatic hemorrhage:
- Subarachnoid hemorrhage
- Subdural hematoma
- Epidural hematoma
Pediatric Considerations |
Additional differential diagnoses include:- Moyamoya disease
- Acute infantile hemiplegia
|
Prehospital
- C-spine precautions if head or neck injury is suspected
- Elevation of head with C-spine control
- Initial prehospital 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:
- Treatment of elevated ICP:
- Controlled ventilation to PaCO2 of 35 Torr
- Fluid restriction; elevate head of bed to 30°
- Mannitol - osmotic diuresis
- Use furosemide as an alternative
- Correct coagulopathies:
- Fresh frozen plasma (FFP)
- Idarucizumab
- Platelets
- Prothrombin complex concentrates (PCCs), vitamin K
- Consider anticonvulsants:
Medication
- Esmolol: 0.5-1 mg/kg initial bolus IV, followed by 50-150 mcg/kg/min infusion
- Enalapril: 1.25-5 mg q6h IV (risk of precipitous BP lowering, test dose 0.625 mg)
- FFP: 10-20 mL/kg IV
- Fosphenytoin: 15-20 mg/kg phenytoin equivalents (PEs) 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
- Idarucizumab: 5 g IV
- Levetiracetam: 500 mg b.i.d (peds: 10 mg/kg/dose) IV; max 3,000 mg/d) IV
- 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/hr infusion
- Nitroprusside: Start 0.25-10 mcg/kg/min IV (max 10 mcg/kg/min); titrate to effect
- PCCs (Kcentra): 25-50 u/kg IV; max 5,000 units
- Phenytoin: 15-20 mg/kg/dose (peds: 15 mg/kg) at rate of <40-50 mg/min
- Platelet: 1-2 units IV in consultation with neurosurgery
- Vitamin K: 5-10 mg IV over 30 min
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
- CaiX, Rosand J. The evaluation and management of adult intracerebral hemorrhage . Semin Neurol. 2015;35:638-645.
- HemphillJC 3rd, GreenbergSM, AngersonCS, et al.; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association . Stroke. 2015;46:2032-2060.
- LaiS, KalantariA, MasonJ, et al. When anticoagulants became a bloody mess . Ann Emerg Med. 2017;70:949-952.
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