Spontaneous Intracranial Hemorrhage (refer to TBI tab for traumatic)
Presentation and buzz words:
Common etiologies: hypertensive, amyloid angiopathy, vascular malformation, neoplasm, hemorrhagic transformation of stroke, septic emboli, trauma
One liner:
When presenting the one liner, note day, location and etiology (if known) of hemorrhage.
Example: "Ms. X is a 35F with PMH X, Y, Z who is admitted to the NeuroICU 3 days post a likely hypertensive basal ganglia hemorrhage."
Diagnose etiology:
DDx: Hypertensive vasculopathy, Cerebral amyloid angiopathy (CAA), hemorrhagic transformation of ischemic stroke, hemorrhagic mass, venous sinus thrombosis, vascular malformations, infectious (endocarditis/mycotic aneurysm), trauma
CT Head non contrast. Look for the hyperdensity. Note location, size, markers of risk for expansion, mass effect?, intraventricular hemorrhage (IVH)?, perihematomal edema?
Location gives you clues regarding etiology
Size and location gives you an idea of how severe
>30cc is considered large per research trials
If markers for risk expansion present, you may want to get a CTH earlier than the typical 6 hour repeat scan
If mass effect, you may want to give hyperosmolar agents or patient may need Neurosurgery
If IVH, patient may need CSF diversion with an external ventricular drain (EVD)
If perihematomal edema, patient may need hyperosmolar treatment
CTA Head with contrast
Look for spot sign - contrast extravasation which suggests ongoing bleeding
Note if any vascular malformation or pathology to account for the intracranial hemorrhage
If hemorrhage deemed to be hypertensive or hemorrhagic transformation if ischemic stroke, consider sending stroke work up to optimize risk factors
If hemorrhage is traumatic, see Traumatic Brain Injury (TBI) section
If etiology found, what are we doing to prevent a future one?
If no etiology has been found, consider obtaining MRI Brain
Intracranial Hemorrhage ICU course/possible complications:
Hematoma expansion
Perihematomal edema +/- mass effect
Intracranial hypertension
Seizures
Calculate severity scores:
Calculate ICH score to assess severity. (NOT a good estimate of mortality as it is only one early point in time)
Volume is calculated by (length * width * # slices) / 4
#ICH Plan Guidance:
Do we have stability? Always report date and time we have stability of bleed.
Repeat CT ("stability") scan typically done at 6 hours until hemorrhage is deemed stable
Did the patient need surgical intervention such as hematoma evacuation?
Was the patient on any antiplatelets, anticoagulation or has any coagulopathy to correct?
If so, did the patient receive any medications to reverse coagulopathy?
For patients presenting with SBP <220, blood pressure goals are SBP 130-150
Consider monitoring with arterial line if labile
Avoid PRNs as it causes swings in blood pressure
Best to start a antihypertensive infusion for smooth control
For patients with initial SBP >220, discuss with the team their optimal SBP
Does patient have EVD or EVD watch?
Note EVD setting and 24h drainage output
ASM given? Only indicated in traumatic hemorrhage or suspected seizure.
Thus, most patients don't need prophylaxis.
While there is no evidence to start empiric seizure prophylaxis, there is evidence cortical hemorrhages are at higher risk for having seizures. If patient is not at baseline, consider getting an EEG to rule out non convulsive seizures/status.
q1h neuro checks during the acute period
For perihematomal edema, consider hyperosmolar therapy if causing mass effect causing symptoms
Sodium goals: what was their last sodium?
Blood glucose goals 140-180
PT/OT/SLP
DVT prophylaxis can be started as soon as 24 hours post stability of head CT
Medications:
Anti-hypertensives (nicardipine or clevidipine)
Restart home meds when able
Special case: thrombolysis-related hemorrhage
Neurologic worsening after tPA/TNK? Hold until STAT imaging done.
STAT CBC, coags, fibrinogen, D-dimer
Type/screen
If confirmed hemorrhage on STAT CT... Reverse thrombolytic.
Cryoprecipitate