• Sign Up

Use coupon code EXTENDEDHOLIDAY2020 at checkout for 20% off

Intracerebral Hemorrhage


Intracerebral Hemorrhage

Article Author:
Devika Rajashekar
Article Editor:
John Liang
Updated:
3/29/2020 9:56:53 PM
For CME on this topic:
Intracerebral Hemorrhage CME
PubMed Link:
Intracerebral Hemorrhage

Introduction

Intracerebral hemorrhage (ICH), a subtype of stroke, is a devastating condition whereby a hematoma is formed within the brain parenchyma with or without extension of blood into the ventricles. Non-traumatic ICH comprises 10-15% of all strokes and is associated with high morbidity and mortality[1].

Risk factors for ICH include chronic hypertension, amyloid angiopathy, anticoagulation (medication), and vascular malformations. The resultant brain injury is often classified as primary, this being the initial damage to the parenchyma by the blood clot, and secondary, or the damage caused by complications of the intracranial blood.

Management of ICH ranges from medical therapy to open surgery to actively evacuate the hematoma with studies still being held to find less invasive therapies to improve prognosis.

 

Etiology

Non-traumatic Intracerebral hemorrhage can be divided into primary and secondary, where primary bleeds account for 85% of all ICH and are related to chronic hypertension or amyloid angiopathy[2]. Secondary hemorrhage is considered to be related but not limited to bleeding diathesis (iatrogenic, congenital, acquired), vascular malformations, neoplasms, hemorrhagic conversion of an ischaemic stroke, and drug abuse.

Primary or spontaneous ICH accounts for over 85% of hemorrhagic strokes[3]. The diagnosis of a primary ICH is often one of exclusion where no other pathological or structural cause is found and is supported by a history of chronic hypertension, increased age, and location of the clot. In patients with chronic arterial hypertension, it is thought that lipohyalinosis and degenerative changes of penetrating arterioles result in Charcot-Bouchard aneurysms in the small arterial vessels supplying deep cerebral structures[1]. Over 60% of primary bleeds are related to hypertension, and these hematomas are most commonly seen in the posterior fossa, pons, basal ganglia, and thalamus[1]. Lobar hemorrhages in older patients are often the distinguishing feature of amyloid angiopathy. This is a degenerative disease thought to be related to alleles of the apolipoprotein E gene, allowing for increased amyloid deposition within vessel walls[4].

In contrast, when an ICH is due to an underlying structural pathology, such as vascular anomalies or malignant tissue, they are categorized as secondary ICH. Vascular lesions include arteriovenous malformations, cavernous angiomas, cerebral aneurysms, and aorto-venous fistulae, and these are often the cause of ICH in the young, otherwise healthy, population. Cerebral hematomas may also be secondary to a primary or metastatic lesion or even the hemorrhagic conversion of a recent ischaemic infarct[4]. Further, congenial and acquired bleeding diathesis is a common factor in ICH’s, becoming more common due to the large population of adults on an anticoagulant (i.e., warfarin) and antiplatelet (aspirin) therapy[3]

Studies have elicited certain tendencies in the population that is seen to suffer ICHs, thereby hypothesizing both modifiable and non-modifiable risk factors. The latter include non-white ethnicity, older age, familial apolipoprotein syndromes, and being male[5]. The radiological finding of cerebral amyloid angiopathy also increases the risk of both lobar and recurrent ICH. Uncontrolled or untreated hypertension is a modifiable risk factor that increases the risk of ICH by two in the aging population. Other adjustable risk factors include abuse of drugs such and alcohol, nicotine, and cocaine[3]

 

Epidemiology

The incidence of stroke, both ischemic and hemorrhagic, in 2010 was approximately 33 million worldwide, with hemorrhagic strokes accounting for nearly a third of cases and over half of all the deaths[4]. Though the worldwide incidence sits at nearly 20 cases per 100,000 people every year[5]the occurrence of ICH in low/middle-income regions is double compared to the rates in more economically developed countries. Fortunately, however, the mortality from such strokes has decreased worldwide[4]. The increased risk in lower-economically developed countries is potentially related to the lack of education regarding primary prevention as well as poorer access to medical care[5].

Stroke, both ischaemic and hemorrhagic, ranks fourth in the list of the leading cause of deaths in the United States, with just under 20% of cerebrovascular incidents in the United States are ICHs[6].

ICH is diagnosed more frequently in the elderly (> 55 years of age) and the male population[7], and a predilection is seen in the African and Asian population[5]. Within the Japanese population, the incidence increases to 55 cases of ICH per 100,000 people, and studies postulate that this is accounted for by the increased prevalence of alcohol use and hypertension[8].

Pathophysiology

Hemorrhages within cerebral parenchyma are often categorized into primary injury, ie the immediate tissue injury from the hematoma and secondary injury - the subsequent pathological change that results from the hemorrhage. Although ICH is commonly considered a single event disease, it is more recently being considered as a dynamic condition with multiple phases these being:

(1) The initial extravasation of blood into the parenchyma

(2) Subsequent bleeding around the clot causing expansion

(3) Swelling or edema around the hematoma [3] 

An acute ICH causes a sudden increase in mass within the parenchyma of the brain, which causes compression and disruption of the surrounding neuronal tissue, leading to a potential compromise of the nearby cell signaling pathways and causing a focal neurological deficit[4]. Blood dissipates within white-matter, leaving small focuses of intact neural tissue amongst the hematoma and around it which is, in theory, salvageable[5]

When the hematoma is within the brainstem, the initial manifestation can be a decreased level of consciousness, along with cardiorespiratory distress or even arrest. One important factor in predicting prognosis and functional outcome of patients is the expansion of the initial hematoma, which is defined on repeat CT scanning as a volume increase of 33-50%[9]. Clot expansion of this volume is seen in just under 40% of patients and is related to increased morbidity and poorer outcomes[4].

Over 70% of ICHs have been noted to expand in the first 24hours from the onset due to continued or repeat bleeding. Studies by Brott et al. [10] revealed that 26% of patients with ICH had hematoma expansion within 1 hour of the first CT scan. Though the mechanism of hematoma growth is not fully understood, it is hypothesized that there is upregulation of the inflammatory cascade, which causes an imbalance in hemostatic mechanisms and increased expression of matrix metalloproteinase[9]. Both untreated hypertension and bleeding diathesis increase the incidence of hematoma growth[5]. It is proposed that there is a disintegration of the blood-brain-barrier, and the mass effect of the clot causes a sudden rise in intracranial pressure (ICP), leading to distortion of the local tissue architecture which can disrupt venous outflow thereby causing vascular engorgement. The local mass effect on the tissues may result in stretching and microscopic rupture of the surrounding vasculature (venules and arterioles), allowing for small focuses of bleeding around the borders of the ICH[9]. The increased ICP results in tissue movement or mass effect, which may lead to herniation syndromes and also causes lower cerebral perfusion pressures (CPP), causing secondary brain injury[4].

Following the vascular bleeding phenomenon, other pathological events occur, which results in secondary brain injury. As a consequence of acute bleeding, the brain parenchyma recruits inflammatory cytokines and thrombin, which causes edema or tissue swelling around the acute hemorrhage [4]. The perihematomal edema is a complication within the hyperacute phase of an ICH and reaches its’ peak at approximately 72 hours post-ictus[7]. The potential mechanism of early edema around the clot is considered to be a vasogenic reaction to pro-osmotic substances such as electrolytes and protein, which are released from the acute hematoma. This is followed by activation of the coagulation cascade and increased expression of thrombin, which may propagate swelling. After the first week, any further edema is related to the cytotoxic effects of hemoglobin breakdown and formation of reactive oxygen species[9]The cause of cerebral ischemia following a hypertensive bleed was considered to be secondary to the compression of cerebral tissue by adjacent hematoma and oedematous tissue under raised pressure. However, there are now studies that have found necrotic tissue in the region around the ICH, thus suggesting apoptosis caused by the expression of nuclear factor-kB within neural-cell nucleoli[5].

 

History and Physical

As with all acute presentations, a concise but thorough history is crucial to forming a diagnosis. Relevant details in the history of ICH include the chronicity of symptoms and the time of ictus. Most commonly, vascular events are sudden and may be precipitated by high energy activities such as exercise or heavy lifting, or use of drugs (cocaine) and alcohol. A significant smoking history has implications in vascular disease such as hypertension and vasculitis which both are risk factors for ICH.

The most common feature of ICH is a sudden onset focal neurological deficit which is determined by the location of the hemorrhage and subsequent edema. This is often associated with a decrease in the patients’ conscious level, measured using the Glasgow coma scale (GCS). Other common symptoms and signs include headache, nausea/vomiting, seizures (both convulsive and non-convulsive) and a raised diastolic blood pressure (>110 mmHg)[2]. Extension of the clot into the ventricles can cause obstructive hydrocephalus which manifests itself with signs and symptoms of raised intracranial pressure including postural headaches (worse on lying flat), papilledema, nausea, vomiting, diplopia, confusion and a reduced conscious level.

Initial evaluation of the patient should include checking for airway patency and appropriate ventilation. Circulation must be assessed next, and one must secure wide bore venous access and aim for systolic blood pressure targets between 120-140 mmHg in order to maintain cerebral perfusion. A very low consciousness level (GCS<8) must be treated as an emergency and obtaining a secure airway in a patient with a low conscious level is a priority. The patient must then have a complete peripheral inspection and examination- this includes checking the patients' pupils as dilation and inactivity of the pupils is a sign of cerebral herniation and must be treated immediately.

Once medically stable, it is pertinent to ascertain confirm a clear history of anticoagulant/ antiplatelet therapy or coagulation disorders and check the patients' clotting function along with other routine blood tests. Any coagulation abnormalities should be discussed with hematologists and corrected appropriately.

Evaluation

A non-contrast CT head remains the gold-standard imaging modality in the initial diagnosis of ICH, as it is easily accessible and fast[2]. A CT head is able to allow for differentiation between the various intracranial pathology including subarachnoid hemorrhage, ischemic stroke, and ICH. It is also able to reveal the extent of the hemorrhage with regards to size, surrounding edema, mass effect, intraventricular clot extension and raised intracranial pressure. MRI, in particular, T2* weighted and gradient-echo sequences, is also a good imaging modality for ICH identification and can also help in revealing old clots, but has the downfall of taking more time and being less easily available[11].

Acute ICH is noted on CT of the head as an area of hyperdensity within the parenchyma with surrounding hypodensity which would indicate perivascular edema. Approximate volumes of the clot can be calculated by multiplying the maximum depth, height and length of the clot in centimeters and dividing this by two[7].

As clot expansion and rebleeding is a major immediate risk in ICH affecting up to 38% of patients with ICH[11], CT head with contrast and CT Angiography (CTA) of the intracranial vessels may be used to help identify vascular pathology that may be the cause for the ICH. The diagnosis of a vascular abnormality can also be useful prior to clot evacuation in the emergent setting, as often surgeons prefer to deal with vascular malformations in a more elective/planned setting. On a contrast CT scan, a hyperdense signal within the hematoma may indicate active bleeding and is colloquially known as the ‘spot sign’. More numerous areas of contrast enhancement may indicate increased areas of active bleeding and therefore, higher risk of clot enlargement[11].  

Vascular lesions causing the ICH is most often suspected in young patients with risk factors, but radiological hints include the presence of SAH, calcification within the hematoma (hyperdense on CT), hematoma shape and its location to major territorial vessels[11]. Aside from CT angiography, vascular abnormalities such as arteriovenous malformations and cavernomas can also be detected on MR angiography and MR venography[11]. An interventional intracranial catheter angiogram is usually performed to confirm the diagnosis of a vascular malformation as this is a dynamic study that gives more information regarding the active filling/emptying phases of the veins and arteries.

 

Treatment / Management

In the prehospital setting, the mainstay of treatment involves airway, breathing, and circulatory support, with the aim being to get the patient to the closest emergency department (with capabilities of managing stroke). A detailed history from any witnesses or family/carers at the site of the incident is always useful as it may provide pertinent information regarding trauma, medical, and drug history[11]

Aggressive early medical management once in an acute hospital setting has been shown to have a direct impact on morbidity and mortality following an ICH. The immediate aim following diagnosis is to minimize the risk of rebleeding and hematoma expansion within the first 24-72 hours[2]. Initially, any and all coagulation abnormalities need to be corrected- this includes treatment of known factor deficiencies and reversal of any anticoagulation agents the patient is known to be on, with the help of the hematologists. In patients known to be taking vitamin K antagonists, guidelines for the management of spontaneous ICH recommends correction (aiming INR < 1.4) using fresh frozen plasma (FFP), vitamin K, prothrombin complex concentrates as well as newly developed recombinant activated factor VIIa[11]. Studies are still ongoing regarding the definitive indication for platelet transfusion in those affected by antiplatelet medication. However, analysis of a smaller case series revealed smaller final ICH size in those who underwent a platelet transfusion within 12 hours of ictus[11].

Most presentations of ICH include raised blood pressure for a variety of physiological reasons including pain, stress, a past history of raised blood pressure and raised ICP. The potential consequence of a persistently raised systolic blood pressure is hematoma expansion, and therefore initial medical management must include treatment of elevated blood pressure. However, blood pressure reduction should take into account the patients' regular blood pressure, as a hypertensive patient may not be able to maintain cerebral perfusion at a significantly lower SBP. American stroke guidelines advise a reduction of blood pressure to a SBP <140 mmHg in those with SBP ranging between 150-220 mmHg. In the population of patients with ICH presenting with SBP > 220 mmHg, it remains pertinent to lower their blood pressure, but in a more controlled way using an infusion with continuous monitoring[11].

Randomized trials initially proved strict blood glucose measurement to be beneficial to the prognosis of ICH, however further studies have revealed increased mortality in those with cerebral hypoglycemia. Guidelines, therefore, suggest aiming for normoglycemia with strict avoidance of hypoglycemia[11]. Patients presenting to hospitals with seizures should be managed with antiseizure medication, such as phenytoin or levetiracetam. However, there is no evidence to suggest that prophylactic anti-seizure medication has a role in reducing the rate of ICH-related epilepsy[11].

In order to prevent secondary brain injury, the aim is to keep CPP>70mmHg. Conservative measures to reduce ICP include keeping the patient head up at 30 degrees, appropriate analgesia, laxatives to avoid straining, hyperventilation, and sedation. In patients who have CT scans that reveal significant mass effect with indications of imminent parafalcine or uncal herniation, osmotic diuretics such as mannitol or hypertonic saline may be rapidly administered, although the benefit from this is not proven[7]. In those patients that require large amounts of sedation to manage seizures or raised ICP, an intracranial pressure monitor can be inserted to provide guidance of the patients’ status while they are not assessable clinically.

Urgent complications of ICH include intraventricular extension and hydrocephalus; the latter developed more quickly in posterior fossa hemorrhages due to the anatomical proximity of the fourth ventricle and, therefore, its ability to become obstructed. CSF diversion is the mainstay of treatment in these cases, and an external ventricular drain (EVD) can be inserted, most commonly into the right lateral ventricle. This allows for a reduction in ICP and herniation[2].

Studies have shown that in ICH within the posterior fossa, surgical evacuation of the clot improves outcomes in good surgical candidates, if the clot is > 3 cm and is causing brainstem compression, decreased level of consciousness and/or hydrocephalus[12]Patients with a higher GCS and decreased volume of blood at the time of surgery are more likely to have a favorable prognosis following the surgical intervention[7].

The ‘Surgical intervention for supratentorial ICH’ or STITCH trial is the largest randomized trial looking into the surgical benefit. In this trial, over 1000 patients with clinical equipoise were randomized into having surgery within 72 hours or into undergoing medical management. The trial concluded that there was no significant benefit from surgical intervention. However, the need for clinical equipoise meant that the patients randomized were already clinically worse off[2]. Further examination of the results revealed that a small group of patients with lobar hemorrhages <1cm from the cortical surface had more encouraging outcomes from surgery with a relative benefit of 29% compared to medical management[7], while those patients who presented with a CGS <8 had poorer results[11]. This led on to a further trial, STICH II aimed to understand the potential outcomes of patients with lobar clots <1 cm from the cortical surface without IVH, with and without surgery. Patients either underwent medical management or medical management with early surgery (<12 hours from the time of randomization). The results of the trial revealed no statistical significance in the two arms, although early surgery benefited the clinically unwell patients more than those who would have likely done well even without surgery[11]As a result of these two large trials, the role of surgical intervention in supratentorial ICH remains controversial. It is largely considered a life-saving intervention is those who are clinically declining[6].

There are some surgeons who would consider a decompressive craniectomy (with or without evacuation of the clot) for selected patients, who show little improvement with medical therapy, with an aim to relieve the mass effect caused by a supratentorial, large ICH. The results of a systematic review of decompressive craniectomy in the setting of supratentorial ICH has shown improved survival rates[13], though morbidity remains high.

More recently, treatment of ICH using minimally invasive techniques are being developed and undertaken worldwide, providing the benefit of less parenchymal brain trauma and reduced surgical time. The current techniques involve stereotactic guidance and insertion of a catheter, which can deliver thrombolysis into the clot and also allow for aspiration if appropriate. The MISTIE trial (Minimally invasive surgery plus rtPA (recombinant tissue plasminogen activator) for intracerebral hemorrhage evacuation) has proposed that the use of rtPA into the clot provides improved hematoma clearance when compared to conservative management[3]. Further, the ‘Clot lysis evaluating accelerated resolution on intraventricular hemorrhage’ (CLEAR-IVH) trial has also concluded that rtPA may provide improved clearance of blood load within the ventricles[3].

 

Differential Diagnosis

Many pathologies can present themselves acutely with symptoms and signs similar to that of acute ICH. The common symptoms of headache and nausea along with clinical manifestations of decreased consciousness, confusion, seizures, and focal neurological deficit are often seen with other intracranial hemorrhages, such as a subarachnoid hemorrhage (SAH) and a subdural hemorrhage (both acute and chronic), neoplasms (primary and secondary), and infection.

The primary feature of a SAH is the pathognomonic sudden onset, severe headache ‘like being hit at the back of the head.’ Apart from this feature, which may not always be expressed so eloquently, patients may present much the same way as those with acute ICH. In a SAH, an unenhanced CT Head would reveal blood within the subarachnoid space and ventricular cisterns rather than within the parenchyma, as seen in an ICH. An acute subdural hematoma may have similar symptoms. However, the key differentiating factor is a history of recent trauma preceding the presentation. Chronic subdural hemorrhages are most commonly seen in the elderly, particularly those on blood-thinning medication, and history is often of recurrent falls followed by a longer duration of headaches and/or confusion and/or focal neurological deficit. Both acute and chronic subdural hematomas can be differentiated on a plain CT head as a crescentic extra-axial collection- hypodense if the blood is chronic and hyperdense in the acute setting.

Brain tumors frequently present insidiously, and due to its gradual growth, most patients are able to compensate until the intracranial pressure is high enough to produce symptoms of headache, nausea, vomiting, seizures, and decreased GCS. On closer examination of the history, there is often evidence of a subtle progressive history and contrasted CT imaging is often required to make a diagnosis. In some situations, patients with neoplastic lesions may present with hemorrhages into a primary or secondary brain tumor, and this can cause diagnostic uncertainty that often requires delayed imaging, in the form of MR, to make a more accurate diagnosis of underlying pathology.

Lastly, infectious collections such as subdural empyema and abscesses can present similarly to acute ICH; however, patients commonly have a history of recent infections in the nasofacial region (ear, sinuses) and/or systemic symptoms of pyrexia and/or rigors. Once again, contrast-enhanced CT and MRI can assist in differentiating the pathology.

Prognosis

Acute ICH can be a catastrophic event with the mortality largely predicted by the hematoma size, location, and the patients' GCS on admission.  At 30 days, the mortality rate can be as high 50%, with most of these deaths occurring within 24 hours of the initial insult[3], with intraventricular blood and hydrocephalus often playing a large part in the patient's deterioration[7]. Patients presenting to hospital with a GCS <9 and a clot size of 60 ml or more have a mortality rate of nearly 90%. Posterior fossa and brainstem hemorrhages carry a poorer prognosis due to the propensity for the development of obstructive hydrocephalus and life-sustaining function, respectively.  Less than 20% of patients that survive are seen to be autonomous at 6 months following the acute hemorrhage[3]. Further, factors such as the patients' age and comorbidities also affect outcomes following ICH.

Although there are no definitive ways of predicting outcomes, early withdrawal of care can, in itself, lead to a self-fulfilling prophecy and therefore full medical care and treatment should be offered to all patients with acute ICH, who do not have an advance directive or known wishes, for the first 24-48 hours post ictus[6].

Complications

Approximately 30% to 50% of patients with ICH are seen to have an extension of the clot into the ventricles. It is thought to be particularly common in thalamic hemorrhages due to the anatomical relations to the third ventricle and the natural tendency for blood to move medially[9]. Patients with intraventricular hemorrhage (IVH) have been seen to have poorer functional outcomes which may be caused by compression and injury to periventricular tissue, inflammatory mediator response to blood products within the ventricular system, as well as obstructive hydrocephalus and its complications[14].

Obstructive hydrocephalus is a complication of IVH and can lead to potentially lethal complications of raised ICP. It is seen more frequently in patients with a larger volume of blood within the ventricular channels[9]. Pacchioni granulations within the arachnoid villi may become partially blocked by intraventricular blood products, thereby resulting in communicating hydrocephalus, which once again can lead to significant morbidity.

Seizures commonly occur as part of the presenting symptoms of ICH, but in some cases may be a delayed complication (two hours post hemorrhage). Just under 70% of seizures are seen within 24 hours of the initial ictus, and the vast majority (90%) occur within 72 hours. Seizures that occur within two hours of the initial ICH (early seizures) are a result of changes in the architecture of neuronal tissues and biochemical dysfunction, whereas delayed seizures are more likely a result of gliosis and tissue scaring[9]. Non-convulsive seizures, detected on cEEG monitoring, are also seen in those with ICH with an incidence rate as high as 28% within 72hours of presentation[9] and are often considered when a patient has a sudden drop in GCS and imaging revealing clot in seizure-prone parts of the brain, ie temporal lobe, cortical surface. Delayed seizures are most commonly associated with increased mass effect and midline shift on imaging[9] and, therefore, may be a clinical sign of hematoma expansion. A study by Passero et al. described the risk of delayed recurrent seizures or epilepsy in those post-ICH to be in the range of 5-27%[15].

Venous thromboembolism (VTE), in the form of deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication seen in most unwell patients admitted to the hospital, but has a rate of about 3% to 7% in those with ICH[9]. Symptomatic DVTs are less common, though rates of asymptomatic DVTs are described as being up to 17%[16]. The high rate of VTE is likely related to the immobility of those with ICH, as many will suffer from hemiplegia/hemiparesis. Further catalyzing the development of VTE is the largely elderly population that develop ICH, the discontinuation of anticoagulant therapy, the diagnostic dilemma of starting prophylactic anticoagulation, as well as an increase in prothrombotic activity seen following acute hemorrhage [9].

Approximately 60% of patients with ICH are seen to develop transient hyperglycemia in the acute setting, lasting up to 72 hours, as part of the body’s natural stress response. There have been studies that show a positive correlation between blood glucose levels and the size of the hematoma, hematoma expansion, and surrounding edema, thus making raised blood glucose an independent predictor of worse functional outcome[9].

Within the acute phase following an ICH, over 70% of patients are found to be hypertensive (BP greater than or equal to 140/90 mmHg), despite having no such history prior to admission. The reasons for this phenomenon are unclear, but the hypothesized theory is that there may be upregulation of neuroendocrine pathways (sympathetic nervous system, renin-angiotensin axis), as well as increased cardiac output as part of the stress response to raised ICP[9].  Though raised blood pressure following ICH is associated with high rates of re-bleed and hematoma expansion and therefore poorer outcomes, the effect of blood pressure levels on mortality exhibit a U-distribution due to hypotension also acting as a factor for poor prognosis due to reduced cerebral perfusion and resultant cerebral ischemia[9].

Deterrence and Patient Education

In recent years, the signs and symptoms of stroke have been increasingly publicized using the pneumonic FAST (facial weakness, arm weakness, speech problems and time to call) and as a consequence, a larger population is able to identify the pertinent characteristics when they see these changes in their friends and family. Further promotion regarding the importance of immediate medical attention may help reduce morbidity and mortality from an ICH.

There are various patient-specific risk factors that may be reversed if patients are made aware of their significance. Hypertensive patients should be made aware of the importance of keeping their blood pressure controlled. Smokers and those who drink large quantities of alcohol should recognize the increased risk they are at for vascular pathologies. One of the more significant risk factors in more recent times is the increased population of patients on anticoagulant and antiplatelet medications. Those on medication that can be checked with regular blood tests, such as Warfarin, should undergo routine testing, and patients and their healthcare team should be prompt in managing raised INR in order to reduce the risk of unwanted bleeding.

Following an ICH, patients and their families should be informed that the disability seen in those who survive acute ICH can be significant, so as to prepare them for a life of dependence. Patients who undergo open brain surgery or those who have seizures will have regulations on their driving status for different time periods depending on their condition and county of residence.  

Enhancing Healthcare Team Outcomes

The cornerstone to good outcomes for patients with acute ICH (who are in a clinically good prognostic category) is often the rapid diagnosis and treatment. In order for this to occur, various staff members in the chain of healthcare professionals tending to the patient have an important function, both in recognizing their individual roles and communicating with their colleagues to offer the best clinical care. This is the very essence of interprofessional teamwork in healthcare.

To begin with, many patients are first attended to by friends and family who have personal knowledge about a patients’ medical and drug history and well as their wishes regarding aggressive medical treatment, which can be pertinent in helping doctors make decisions later in their healthcare journey. Paramedics are often the first responders to acutely unwell patients with ICH, and their ability to gain an eye-witness account, medical and drug history is crucial (especially when the patient has a decreased GCS). While being transferred to the local emergency department, the paramedic team must be able to stabilize a patient and handover any important information they collected to the nursing team and doctors in the hospital.

The nursing team is often in charge of obtaining the patients' vital signs and observations once admitted, and rapid recognition of an unsafe airway, respiratory or circulatory failure is important so the appropriate medical teams can get involved to treat the immediate threats to the patient’s life. The doctors must have the ability to gain a history from either the patient, family, or first-responder team, and make a rapid plan for investigations. The radiology team (both radiologists and radiographers) have an important role in performing appropriate imaging in a time-critical manner, and this is crucial to the diagnosis.

Once a diagnosis of ICH is made, the neurology and neurosurgery team work together with the family and patient to make an informed plan about what the most appropriate management should and will be. If a patient is for conservative management, intensive care nurses and doctors are responsible for providing aggressive medical management under the guidance of the stroke physicians. If a decision is made for surgery, then there is a need for the neurosurgeons and intensivists to work together to allow for the patient to have the best possible outcome.

Lastly, those fortunate patients who do well will most frequently require large amounts of support from the occupational therapists, speech and language therapist, and physiotherapy team to help to rehabilitate the patient to their maximum potential, thereby giving them the best outcome possible.  

‘The Guidelines for the Management of spontaneous intracerebral hemorrhage’ from the American stroke association was published following thorough peer review in 2015 and includes results from phase 3 trials.  The guidelines aim to provide healthcare professionals with succinct advice with regard to the recognition and management of ICH[11]. [Level 1]

 

 

 


References

[1] Ziai WC,Carhuapoma JR, Intracerebral Hemorrhage. Continuum (Minneapolis, Minn.). 2018 Dec;     [PubMed PMID: 30516598]
[2] Flower O,Smith M, The acute management of intracerebral hemorrhage. Current opinion in critical care. 2011 Apr;     [PubMed PMID: 21169826]
[3] Elliott J,Smith M, The acute management of intracerebral hemorrhage: a clinical review. Anesthesia and analgesia. 2010 May 1;     [PubMed PMID: 20332192]
[4] Aiyagari V, The clinical management of acute intracerebral hemorrhage. Expert review of neurotherapeutics. 2015;     [PubMed PMID: 26565118]
[5] Qureshi AI,Tuhrim S,Broderick JP,Batjer HH,Hondo H,Hanley DF, Spontaneous intracerebral hemorrhage. The New England journal of medicine. 2001 May 10;     [PubMed PMID: 11346811]
[6] Morotti A,Goldstein JN, Diagnosis and Management of Acute Intracerebral Hemorrhage. Emergency medicine clinics of North America. 2016 Nov;     [PubMed PMID: 27741993]
[7] Rymer MM, Hemorrhagic stroke: intracerebral hemorrhage. Missouri medicine. 2011 Jan-Feb;     [PubMed PMID: 21462612]
[8] Kagan A,Harris BR,Winkelstein W Jr,Johnson KG,Kato H,Syme SL,Rhoads GG,Gay ML,Nichaman MZ,Hamilton HB,Tillotson J, Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: demographic, physical, dietary and biochemical characteristics. Journal of chronic diseases. 1974 Sep;     [PubMed PMID: 4436426]
[9] Balami JS,Buchan AM, Complications of intracerebral haemorrhage. The Lancet. Neurology. 2012 Jan;     [PubMed PMID: 22172625]
[10] Brott T,Broderick J,Kothari R,Barsan W,Tomsick T,Sauerbeck L,Spilker J,Duldner J,Khoury J, Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997 Jan;     [PubMed PMID: 8996478]
[11] Hemphill JC 3rd,Greenberg SM,Anderson CS,Becker K,Bendok BR,Cushman M,Fung GL,Goldstein JN,Macdonald RL,Mitchell PH,Scott PA,Selim MH,Woo D, Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;     [PubMed PMID: 26022637]
[12] Da Pian R,Bazzan A,Pasqualin A, Surgical versus medical treatment of spontaneous posterior fossa haematomas: a cooperative study on 205 cases. Neurological research. 1984 Sep;     [PubMed PMID: 6151139]
[13] Takeuchi S,Wada K,Nagatani K,Otani N,Mori K, Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage. Neurosurgical focus. 2013 May;     [PubMed PMID: 23634924]
[14] Bhattathiri PS,Gregson B,Prasad KS,Mendelow AD, Intraventricular hemorrhage and hydrocephalus after spontaneous intracerebral hemorrhage: results from the STICH trial. Acta neurochirurgica. Supplement. 2006;     [PubMed PMID: 16671427]
[15] Passero S,Rocchi R,Rossi S,Ulivelli M,Vatti G, Seizures after spontaneous supratentorial intracerebral hemorrhage. Epilepsia. 2002 Oct;     [PubMed PMID: 12366733]
[16] Lacut K,Bressollette L,Le Gal G,Etienne E,De Tinteniac A,Renault A,Rouhart F,Besson G,Garcia JF,Mottier D,Oger E, Prevention of venous thrombosis in patients with acute intracerebral hemorrhage. Neurology. 2005 Sep 27;     [PubMed PMID: 16186525]