Day #187 - Intracranial Hemmorhage

Today we discussed a case of intracranial hemorrhage presenting as a stroke like syndrome with confusion, aphasia and neglect.

I have previously blogged about acute confusion and aphasia here.

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Intracerebral Hemorrhage:

• Second most common cause of stroke syndrome
• Mortality -- ICH Score
• GCS 3-4 (=2 pts) 5-12 (=1 pt)
• ICH greater than 30cm2 = 1 pt
• Intraventricular extension (spills into ventricles) = 1 pt
• Infratentorial =1
• Age greater than 80 =1

ICH scores of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100 percent mortality

The key aspects to management of ICH include:

• Reverse coagulopathies
• Reduce blood pressure (goal generally 160-180 systolic) to minimize further bleeding and maximize cerebral perfusion

Reduce risk of progression:

• Stop ASA/plavix -- can consider restarting day 10
  
• Reverse anticoagulation from warfarin -- Prothrombin Complex Concentrate and Vitamin K or FFP
  
  • Can consider restarting @ 2 weeks (tight monitoring) and usually only for hard indications like mechanical heart valves.
    
• Reverse heparin -- protamine sulfate
• Initial excitement about rFVIIa -- now in question.
  

Treat increased ICP:

• Head of bed at 30 degrees
• Analgesia
• Mannitol, surgery if profound increase

Blood Pressure Control:

• Greater than 200 systolic or MAP 150 -- reduce to 160-180
• 160-180 and increased ICP -- consider ICP monitoring and aim for CPP (MAP-ICP) of 60-80
• 160-180 no increased ICP -- goal 160 MAP 110

Surgery has a limited role but can be life saving.