ICH Initial Management

Oxygenation and ventilation are initially the top priority.

Assess this first and consider intubation if:

• Insufficient airway protection , often if GCS < 8
• Hypoventilation – a high or rising PaCO2
• Hypoxemia
• Unable to safely manage without e.g for CT scan
• Borderline situation and about to have an anaesthetic for procedure e.g. angiogram, EVD insertion, clipping of aneurysm

2/3 Patients won’t need intubation REF

Intubation / anaesthesia must take these factors into account:

• Avoid hypertension (SBP > 180 mmHg) to reduce ongoing bleeding
• Avoid hypotension (SBP < 120 mmHg) to maintain cerebral perfusion to threatened penumbra around ICH
• Minimise stimulation of oropharynx to avoid hypertensive event
• Maintain oxygenation and normocapnoea throughout

Here’s a simulated example of how to intubate a patient where these priorities apply:

More resources on the Neurocritical Care Intubation

Time course of symptoms: time of initial onset (or when last seen normal)

Initial symptoms and progression

Was there a seizure?

Hypertension history

Drugs, specifically:

Sympathomimetics: amphetamines, cocaine

Appetite suppressants or nasal decongestants (pseudoephedrine)

Dietary supplements: especially ephedra alkaloids (ma huang)

Anticoagulants: warfarin, dabigatran, apixaban

Antiplatelet drugs: aspirin, clopidogrel, prasugrel, NSAIDS

History of alcohol abuse

Past medical history, specifically:

Coagulopathies

History of dementia CAA association)

Liver disease

Previous stroke

History of known vascular abnormalities (AVM, venous angioma)

 Tumor: known history of cancer, especially those that tend to go to brain (lung, breast, GI, renal, melanoma) or associated with coagulopathy (leukemia)

Vascular risk factors (Ischemic stroke, Prior ICH, Hypertension, Hyperlipidemia, Diabetes, Metabolic syndrome)

Recent surgery: especially carotid stenting or endarterectomy, procedures requiring heparin

Recent childbirth and/or eclampsia or preeclampsia

History of recent trauma

A neurological exam is an essential part of the initial workup.

It informs the differential diagnosis, prognosis and potentially management.

A NIHSS is a systematic and standardised way to do this.

If there is clinical evidence of EICP, consider emergent empirical treatment such as hyperosmolar therapy

Bloods

FBC (?thrombocytopenia ?anaemia ?inflammatory marker, think endocarditis)

EUC (?uraemia, ?renal failure affecting drug dosing)

LFT (high bilirubin, low albumin in chronic liver disease CLD)

Coags (warfarin, CLD, other forms of coagulopathy)

Fibrinogen (?deficient)

Glucose (avoid hypo / hyper)

Troponin (elevation associated with worse outcomes)

+/- Group & Hold (If surgery likely)

Lines

> Arterial line needed for tight blood pressure control

CVC often needed for infusions of antihypertensive agents.

Not top priority in resus though

Urine

> Tox screen

> Cocaine and the sympathomimetics associated with ICH

ECG

> ? myocardial ischaemia, ?old infarct, ?chronic hypertensive changes

> Monitor for 24-72 hours of admission REF

The critical investigation

May point towards aetiology

Key part of prognostication

> Neurosurgery urgent if hydrocephalus or posterior fossa ICH

Also think about:

• Volume of ICH
• Whether supratentorial or infratentiorial
• Whether there is IVH

For volume, use the ABC/2 method to estimate elliptoid volume

REF

Haematoma Growth

Occurs in up to 1/3 of ICH

Usually occurs in first 6h

Can continue for up to 48h, especially if coagulopathic / on anticoagulants

Have low threshold for repeating CT to see if surgery indicated or HCP nessessitates an EVD

Look for the “Black Hole Sign”

REF

ECG (routine and for evidence of chronic hypertension)

Urine drug screen if appropriate

See page on ANTICOAGULATION REVERSAL

Don’t give platelets just because pt has been on aspirin or clopidogrel, this worsens outcomes

Controversial topic and we may not have the definitive answer yet.

Rationale for blood pressure reduction is to theoretically reduce haematoma expansion.  This would be expected to be most effective within the period that the hematoma is expanding (typically the first six hours, but potentially longer in coagulopathic patients).

However if cerebral perfusion pressure is reduced too much (by reducing BP), the area around the haematoma may become ischaemic, necrotic and then oedematous, and precipitate secondary brain insults.

So what to do?

Fortunately guidelines have been published in 2022 REF: AHA/ASA 2022 Guidelines

> 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 Manage it?

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

Use titratable IV agents as per your local institutional guideline

Frequently check NIBP, initiate treatment, then insert arterial line

> 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.

When communicating to Neurosurgery, Neurology and ICU try to cover:

> Age

> GCS, pupil exam, neuro exam, NIHSS

> Haematoma volume and location

> Other CT findings (intraventricular hemorrhage, hydrocephalus, black hole sign, spot sign)

> Airway status

> Blood pressure, target, and treatment initiated

> Coagulation results and reversal if given

> Medications given