Intraparenchymal Hemorrhage

LITERATURE

• AHA 2022 Guidelines

• GOAL IS TO PREVENT FURTHER BLEEDING (by stabilizing blood pressure and by correcting coagulopathies)
• General Management Considerations:
  • Intubate based on clinical status with consideration of various scales (GCS, HH, ICH, etc)
  • q1h neuro checks
  • keep head of bed 30°
  • Goal euglycemia (140-180)
  • Goal normothermia
  • Goal Na 135-145 and higher if cerebral edema is a concern.

• Assess the severity intracerebral hemorrhage
  • ICH Scale

Component	ICH Score Points
GCS score
3–4	2
5–12	1
13–15	0
ICH volume, cm3
≥30	1
<30	0
IVH
Yes	1
No	0
Infratentorial origin of ICH
Yes	1
No	0
Age, y
≥80	1
<80	0
Total ICH Score	0–6

0 – 0% mortality risk; 1: 13% mortality risk; 2: 26% mortality risk; 3: 72% mortality risk; 4: 97% mortality risk; 5: 100% mortality risk; 6 : Estimated 100% mortality risk

Level of Blood Pressure Control is Controversial

• 2022 Guidelines recommend steady titration of blood pressure to range of 130-150mmHg
• Further Reading – INTERACT2 and ATACH-2 Trials
• Agents: hydralazine, labetalol, nicardipine
  • avoid nitrates due to risk for cerebral vasodilation and cerebral edema
• Correct coagulopathies & stop all anti-coagulants/anti-platelet
  • FFP 15-20 mL/kg
  • If on Vitamin K Antagonist à PCC and Vitamin K 5 mg or 10 mg IV/PO daily for several days
  • Platelets for antiplatelet agents are not indicated (increased mortality).
• If severe coagulation factor deficiencies or thrombocytopenia consider replacement with PCC or platelets
• CTA/MRA once stable, monitor for seizure activity
• Most supratentorial ICH do not need neurosurgical intervention. (ongoing studies)
• Call NSGY if:
  • Cerebellar hemorrhage + deteriorating neurologically OR who have brainstem compression &/or hydrocephalus! Need surgical evacuation
  • Strongly consider neurosurgical intervention in posterior fossa or temporal lobe hemorrhage > 3 cm
• Patients at risk for cerebral edema and hydrocephalus (see cerebral edema and ICP below)