ICH in ICU

If initial SBP 150-220 mmHg, target NI SBP 130-150 mmHg

If initial SBP > 220 mmHg, target NI SBP 140-180 mmHg

Ensure coagulation normalised

Manage EICP

Have low threshold to re-image

Surgery if indicated, particularly for HCP or posterior fossa ICH

Look for and treat underlying cause

Look for and treat seizures

Avoid hyperthermia

Euglycaemia

Start chemical VTE prophylaxis day 1-4 when haematoma has stopped expanding

Monitor for swallowing dysfunction

Neurological observations include:

• GCS assessment and motor strength.
• NIHSS every 4 hours

Changes in neurological observations must be escalated promptly as it may represent a time-dependent emergency e.g.

Haematoma expansion

Now Intraventricular hameorrhage

Hydrocephalus

New clot formation and vessel occlusion

Worsening cerebral oedema with mass effect

• Reduced level of consciousness, fluctuations or a change in Glasgow Coma Score
• Pupillary changes – unequal, dilated, pinpoint or non-reactive to light
• New onset or worsening of a neurological deficit such as weakness in the face, arm or leg down one side of the body, as well as problems with swallow, speech, sensation or vision.
• A change in the NIHSS score
• Severe headache
• Nausea and vomiting
• Blood pressure out of target range

Continuous pulse oximetry to ensure hypoxia is prevented

Cardiac telemetry, at risk of dysrhythmia

Invasive and non-invasive blood pressure monitoring

If EVD in situ for HCP or EICP:

ICP

Amount of fluid drained per hour and 24hs

CSF analysis twice weekly

If presenting SBP 150-220 mmHg, aim Non-Invasive SBP 130-150 mmHg

Try to lower BP smoothly

Start treatment within 2 hours

Achieve target within 1 hour of starting

Avoid variability

> Arterial line usually essential

> Central line often required

If initial SBP > 220 mmHg, aim SBP 140-180 mmHg

– Some evidence of increased harm in rapid reduction of BP in this group

How to achieve this?

Treat pain first (especially in intubated patients, elevates BP)

Use titratable IV agents as per your local institutional guideline

> Remember SMOOTH, MINIMAL VARIABILITY

Bolus doses e.g.

• IV hydralazine 10 mg q15 min
• IV labetalol 20 mg over 2 minutes
• IV metoprolol 5 mg over 5 minutes

Infusions e.g.

> Clevidipine a newer dihydropyridine calcium-channel blocker that has a short half life may be given via continuous infusion and is easily titratable

> Avoid GTN, ideally avoid sodium nitroprusside too; these are venodilators and can potentially increase ICP and potentially haematoma growth.

REF: AHA/ASA 2022 Guidelines

REF AHA/ASA 2022

Repeat coagulation profile

Treat thrombocytopenia, aim Plt > 100K if possible

ASPIRIN or CLOPIDOGREL

Don’t give platelets UNLESS neurosurgery happening

No evidence for desmopressin (DDAVP)

Warfarin

4 Factor PCC better than FFP

Also give 10 mg Vit K

Dabigatran

Consider idarucizumab 5 g, provided as two separate vials each containing 2.5 g/50 mL idarucizumab

Activated charcoal (50 gm) should also be given if ICH occurs within 2 hours of most recent dabigatran dose.

If idarucizumab is not available, consider activated PCC

These approaches do not fully reverse dabigatran

Direct Xa inhibitors

(Rivaroxaban, apixaban, edoxaban, betrixaban)

Andexanet alpha

Dosing depends on which agent

Activated PCC

Heparins (unfractionated or LMWH)

Protamine

PROTHROMBOTICS

No current evidence or recommendation for Recombinant Factor VIIa or TXA

REF AHA/ASA Guidelines 2022

Occur in up to 8-20% most in 1st 24 h

Lobar ICH a risk factor

Non-convulsive seizures more common than convulsive

These may be associated with expanding haematoma

Have low threshold to obtain EEG

Consider continuous EEG in unconscious patients if available

If seizure (clinical or electroencephalographic) seen, treat.

Levetiracetam 1st agent of choice

Prophylactic ASMs not recommended but that was based on when phenytoiun was ASM usually used

Risk / benefit of prophylactic levetiracetam unknown.

BLOOD GLUCOSE MONITORING & CONTROL

• BGL should checked on admission to ICU and every 6 hours thereafter
• BGL should be maintained 6-10 mmol/L

Fever is common after ICH and is associated with poorer outcomes.

It occurs in 1/3 of patients.

Of these, 2/3 have do not have an infective source found REF

Cultures should be taken, including from CSF.

Antibiotics are usually  not given unless there is a clear source or other signs of sepsis

Antipyretic therapy, comprising regular paracetamol or physical cooling measures should be used routinely where fever i.e. temperature> 37.5 degrees occurs

There is no evidence for routine hypothermia for ICH

All patients receive intermittent pneumatic compression stockings

Elastic compression stockings are not used

In non-ambulatory patients, low-dose UFH or LMWH prophylaxis at 24 to 48 hours from ICH onset is reasonable

It may be reasonable to first document haemorrhage stability on CT if LMWH prophylaxis is started in the 24- to 48-hour window after ICH onset.

REF 2022

One approach from a Finnish group:

SMASH-U

REF

Further Investigations

CTA +/- Venogram:

• To exclude underlying vascular malformation, aneurysm (rare cause of ICH), tumor (which is usually better diagnosed on contrast MRI), Moya Moya, vasculitis or cerebral sinus thrombosis.
• Perform for
  • Lobar spontaneous ICH if age < 70
  • Deep/ post fossa ICH and age < 45
  • Deep/ post fossa ICH, age 45-70 and no history of hypertension
• In these patients, if CTA/CTV negative, then do a MRI/MRA
• If MRI/MRA negative, then consider DSA

MRI / MRA

• To investigate for underlying vascular malformations / tumour
• Reveals cerebral amyloid angiopathy better than CT
• In patients with spontaneous ICH and a CTA or magnetic resonance angiography (MRA) suggestive of a macrovascular cause, catheter intra-arterial DSA should be performed as soon as possible to confirm and manage underlying intracranial vascular malformations.

DSA

• See above
• If intra-ventricular haemorrhage (IVH) and no detectable parenchymal haemorrhage
• If all investigations negative including DSA, consider repeating DSA in 3-6 months

Reference AHA/ASA ICH Guidelines 2022

DYSPHAGIA & NUTRITION ASSESSMENT

All stroke patients are to be kept ‘Nil By Mouth’ (NBM) until swallow assessment performed (e.g. ASSIST Screen)

If patient fails the assessment, they should be kept NBM until Speech Pathology review.

An NGT may be inserted 8 hours following administration of rt-PA, although it may be more appropriate to wait until 24 hours in the absence of significant underlying nutritional risk or essential oral medications (e.g. Parkinson’s disease medications), particularly where NGT insertion is anticipated to be difficult.

A specific situation, often highly charged

Patients who show evidence of haemorrhage following rtPA warrant consideration of rtPA reversal in select cases.

Thrombolysis is not easily reversed but guidelines suggest:

Cryoprecipitate as soon as possible after detection of sICH with empirically transfusing with 10 U cryoprecipitate and anticipate giving more cryoprecipitate as needed to achieve a fibrinogen level of ≥150 mg/dL.

Platelet transfusion is not routinely recommended except in those with thrombocytopenia (platelet count <100 000/μL).

Use of 4-factor PCC/ prothrombin complex concentrate is recommended in patients on warfarin treatment before getting tPA (those with a sub therapeutic INR who qualified for IV thrombolysis). PCC is the preferred modality, but if unavailable, fresh frozen plasma may be used. Adjunctive therapy with vitamin K should also only be reserved for this subgroup that was on warfarin before receiving alteplase.

Antifibrinolytics have limited data but should be considered in patients with sICH, particularly in patients who decline blood products.

Given lack of safety data, use of activated factor VIIa is not recommended.

Patients should have BP parameters reviewed and managed like other ICH patients.

REF

Clear Neurosurgery Indications

Posterior Fossa (cerebellar) haemorrhage

If:

• GCS </= 13
• Haematoma > 4 cm
• Hydrocephalus
• Brain stem compression

REF

Hydrocephalus

Often due to extension of ICH to IVH

> Indication for an External Ventricular Drain (EVD)

Poor prognostic sign if this is required

> Avoid an EVD for HCP from cerebellar ICH – this may cause upward herniation. Evacuate clot instead, +/- EVD.

Less Clear Indications

Evidence is lacking to support surgery for supratentorial ICH.

The STICH Trial was an RCT comparing medical management with early haematoma evacuation. It showed no benefit from surgery.

The STICH-II Trial looked specifically at superficial lobar ICH. Again there was no benefit from surgery.

There has been much debate about what these studies mean and many neurosurgical centres continue to perform surgery for supratentorial ICH

The reason that these studies showed no benefit may be because some patients benefited and some were harmed.

A recent meta-analysis of all the data suggested surgery was harmful for small lesions with increasing benefit for larger volumes (up to a point) and was beneficial for patients with a GCS 10-13 but not for more or less conscious patients.

A modern neurosurgical textbook suggests consider evacuation if:

• Superficial lobar ICH (not basal ganglia / thalamus ICH)
• There’s marked mass effect (with oedema and midline shift)
• Symptoms are due to mass effect rather than brain injury from the ICH
• Volume 10-30 ml
• Refractory EICP
• Rapid deterioration
• <50 years old
• < 24 hours from onset

Minimally Invasive Surgery

Emerging evidence suggests that minimally invasive surgery could be more promising (with several ongoing trials)

Listen to this talk on the EVACUATE trial, a randomized controlled trial of ultra-early, minimally invasive, haematoma evacuation versus standard care within 8 hours of intracerebral hemorrhage.