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IntracranialHemorrhageTreatment&Management

IntracranialHemorrhageTreatment&Management
Author:DavidSLiebeskind,MDChiefEditor:HelmiLLutsep,MDmore...
Updated:Dec4,2014

MedicalCare
Medicaltherapyofintracranialhemorrhageisprincipallyfocusedonadjunctivemeasurestominimizeinjuryandto
stabilizeindividualsintheperioperativephase.Recentclinicaltrialdatasuggeststhattreatmentwithrecombinant
factorVIIa(rFVIIa)within4hoursaftertheonsetofintracerebralhemorrhagelimitsthegrowthofthehematoma,
reducesmortality,andimprovesfunctionaloutcomesat90days. [10]However,furtherstudyofthismedicationina
broadercohortdidnotresultinimprovedclinicaloutcomes.Thisinterventionmayalsoresultinasmallincreasein
thefrequencyofthromboembolicadverseevents.TheearlyuseofrFVIIainpatientswithheadinjurywithout
systemiccoagulopathymayreducetheoccurrenceofenlargementofcontusions,therequirementoffurther
operation,andadverseoutcome. [11]
Performendotrachealintubationforpatientswithdecreasedlevelofconsciousnessandpoorairway
protection.
Cautiouslylowerbloodpressuretoameanarterialpressure(MAP)lessthan130mmHg,butavoid
excessivehypotension.Earlytreatmentinpatientspresentingwithspontaneousintracerebralhemorrhageis
importantasitmaydecreasehematomaenlargementandleadtobetterneurologicoutcome. [12]
Rapidlystabilizevitalsigns,andsimultaneouslyacquireemergentCTscan.
Intubateandhyperventilateifintracranialpressureisincreasedinitiateadministrationofmannitolforfurther
control.
Maintaineuvolemia,usingnormotonicratherthanhypotonicfluids,tomaintainbrainperfusionwithout
exacerbatingbrainedema.
Avoidhyperthermia.
Correctanyidentifiablecoagulopathywithfreshfrozenplasma,vitaminK,protamine,orplatelet
transfusions.
Initiatefosphenytoinorotheranticonvulsantdefinitelyforseizureactivityorlobarhemorrhage,andoptionally
inotherpatients.Levetiracetamhasshownefficacyinchildrenforprophylaxisofearlyposthemorrhagic
seizures. [13]Additionaldatasuggestthatlevetiracetamismoreeffectivethanphenytoinforseizure
prophylaxiswithoutsuppressionofcognitiveabilitiesinpatientswithICH. [14]
FacilitatetransfertotheoperatingroomorICU.
WhilereducingSBPwithintravenousnicardipinehydrochloridedoesnotsignificantlyreducehematoma
expansioninpatientswithICH,theAntihypertensiveTreatmentofAcuteCerebralHemorrhagestudy
supportsfurtherstudiestoevaluatetheefficacyofaggressivepharmacologicSBPreduction. [15]

SurgicalCare
Considernonsurgicalmanagementforpatientswithminimalneurologicaldeficitsorwithintracerebral
hemorrhagevolumeslessthan10mL.
Considersurgeryforpatientswithcerebellarhemorrhagegreaterthan3cm,forpatientswithintracerebral
hemorrhageassociatedwithastructuralvascularlesion,andforyoungpatientswithlobarhemorrhage.The
commonhypertensivehemorrhagesinthebasalgangliahavenotbeenshownclearlytobenefitfromsurgery,
althoughcaseserieswithfavorableoutcomesafterstereotacticneedleevacuationorendoscopicdrainage
havebeenreported.Inthepast,standardcraniotomywithevacuationofthehematomadidnotappearto
improveoutcomes.
Othersurgicalconsiderationsincludethefollowing:
Clinicalcourseandtiming
Patient'sageandcomorbidconditions
Etiology
Locationofthehematoma
Masseffectanddrainagepatterns
Surgicalapproachesincludethefollowing:
Craniotomyandclotevacuationunderdirectvisualguidance
Stereotacticaspirationwiththrombolyticagents
Endoscopicevacuation

Consultations
Neurosurgeon
Neurologist
Interventionalneuroradiologist
Rehabilitationspecialist

Diet
Employaspirationprecautionsandobtainevaluationofpatient'sswallowing.
Initiateenteralfeedingsassoonaspossible.Thepatientmayrequireplacementofanasogastrictubeor
percutaneousdevice.

Activity
Maintainbedrestduringthefirst24hours.

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Followwithprogressiveincreaseinactivity.
Avoidstrenuousexertion.

ContributorInformationandDisclosures
Author
DavidSLiebeskind,MDProfessorofNeurology,ProgramDirector,VascularNeurologyResidencyProgram,
UniversityofCalifornia,LosAngeles,DavidGeffenSchoolofMedicineNeurologyDirector,StrokeImaging
Program,CoMedicalDirector,CerebralBloodFlowLaboratory,AssociateNeurologyDirector,UCLAStroke
Center
DavidSLiebeskind,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurology,
AmericanHeartAssociation,AmericanMedicalAssociation,AmericanSocietyofNeuroimaging,American
SocietyofNeuroradiology,NationalStrokeAssociation,andStrokeCounciloftheAmericanHeartAssociation
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
JeffreyLSaver,MD,FAHA,FAANProfessorofNeurology,Director,UCLAStrokeCenter,Universityof
California,LosAngeles,DavidGeffenSchoolofMedicine
JeffreyLSaver,MD,FAHA,FAANisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanHeartAssociation,AmericanNeurologicalAssociation,andNationalStrokeAssociation
Disclosure:UniversityofCaliforniaTheUniversityofCaliforniaRegentsreceivefundsforconsultingserviceson
clinicaltrialdesignprovidedtoCovidien,Stryker,andLundbeck.Consulting
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
HowardSKirshner,MDProfessorofNeurology,PsychiatryandHearingandSpeechSciences,Vice
Chairman,DepartmentofNeurology,VanderbiltUniversitySchoolofMedicineDirector,VanderbiltStroke
CenterProgramDirector,StrokeService,VanderbiltStallworthRehabilitationHospitalConsultingStaff,
DepartmentofNeurology,NashvilleVeteransAffairsMedicalCenter
HowardSKirshner,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofNeurology,AmericanHeartAssociation,AmericanMedicalAssociation,AmericanNeurological
Association,AmericanSocietyofNeurorehabilitation,NationalStrokeAssociation,PhiBetaKappa,and
TennesseeMedicalAssociation
Disclosure:Nothingtodisclose.
SelimRBenbadis,MDProfessor,DirectorofComprehensiveEpilepsyProgram,DepartmentsofNeurology
andNeurosurgery,TampaGeneralHospital,UniversityofSouthFloridaCollegeofMedicine
SelimRBenbadis,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurology,
AmericanAcademyofSleepMedicine,AmericanClinicalNeurophysiologySociety,AmericanEpilepsySociety,
andAmericanMedicalAssociation
Disclosure:UCBPharmaHonorariaSpeaking,consultingLundbeckHonorariaSpeaking,consultingCyberonics
HonorariaSpeaking,consultingGlaxoSmithKlineHonorariaSpeaking,consultingSunovionConsultingfee
NoneSupernusHonorariaSpeaking,consultingUpsherSmithNoneEisaiHonorariaSpeakingandteaching
ChiefEditor
HelmiLLutsep,MDProfessorandViceChair,DepartmentofNeurology,OregonHealthandScience
UniversitySchoolofMedicineAssociateDirector,OregonStrokeCenter
HelmiLLutsep,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurologyand
AmericanStrokeAssociation
Disclosure:StrykerNeurovascularConsultingfeeReviewpanelmembership

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