The Acute Management of Intracerebral Hemorrhage

Justine Elliott, Martin Smith
2010 Anesthesia and Analgesia  
Intracerebral hemorrhage (ICH) is a devastating disease with high rates of mortality and morbidity. The major risk factors for ICH include chronic arterial hypertension and oral anticoagulation. After the initial hemorrhage, hematoma expansion and perihematoma edema result in secondary brain damage and worsened outcome. A rapid onset of focal neurological deficit with clinical signs of increased intracranial pressure is strongly suggestive of a diagnosis of ICH, although cranial imaging is
more » ... ial imaging is required to differentiate it from ischemic stroke. ICH is a medical emergency and initial management should focus on urgent stabilization of cardiorespiratory variables and treatment of intracranial complications. More than 90% of patients present with acute hypertension, and there is some evidence that acute arterial blood pressure reduction is safe and associated with slowed hematoma growth and reduced risk of early neurological deterioration. However, early optimism that outcome might be improved by the early administration of recombinant factor VIIa (rFVIIa) has not been substantiated by a large phase III study. ICH is the most feared complication of warfarin anticoagulation, and the need to arrest intracranial bleeding outweighs all other considerations. Treatment options for warfarin reversal include vitamin K, fresh frozen plasma, prothrombin complex concentrates, and rFVIIa. There is no evidence to guide the specific management of antiplatelet therapy-related ICH. With the exceptions of placement of a ventricular drain in patients with hydrocephalus and evacuation of a large posterior fossa hematoma, the timing and nature of other neurosurgical interventions is also controversial. There is substantial evidence that management of patients with ICH in a specialist neurointensive care unit, where treatment is directed toward monitoring and managing cardiorespiratory variables and intracranial pressure, is associated with improved outcomes. Attention must be given to fluid and glycemic management, minimizing the risk of ventilator-acquired pneumonia, fever control, provision of enteral nutrition, and thromboembolic prophylaxis. There is an increasing awareness that aggressive management in the acute phase can translate into improved outcomes after ICH. (Anesth Analg 2010;110:1419 -27) I ntracerebral hemorrhage (ICH) is a spontaneous extravasation of blood into brain parenchyma. The overall incidence is 12 to 15 cases per 100,000 population per year, 1 and it is the cause of 10% to 15% of first-ever strokes. 2 It is more common in the elderly 3 and in those of African 4 or Asian ethnicity, 5 and the incidence is substantially increased in those receiving anticoagulant therapy. 6 Although ICH accounts for only 10% to 30% of all strokerelated admissions to hospital, it is one of the major causes of stroke-related death and disability. Overall mortality approaches 50% at 30 days, 7,8 and approximately half of all ICH-related mortality occurs within the first 24 hours after the initial hemorrhage. 9 Functional outcome in survivors is also poor with fewer than 20% being independent at 6 months. 2 In up to 40% of cases, the hemorrhage extends into the ventricles (intraventricular hemorrhage [IVH]) and this is associated with obstructive hydrocephalus and worsened prognosis. 5 Other factors associated with poor outcome include large hematoma volume (Ͼ30 mL), posterior fossa location, older age, and admission mean arterial blood pressure (MAP) Ͼ130 mm Hg. 8, 9 More than 85% of ICH occurs as a primary (spontaneous) event related to rupture of small penetrating arteries and arterioles that have been damaged by chronic arterial hypertension or amyloid angiopathy. Sixty percent to 70% of primary ICH is hypertension related 10 and, in the elderly, amyloid angiopathy accounts for up to one-third of the cases. 11 Secondary ICH can be related to multiple causes (Table 1) . 11 This review discusses the current understanding of the pathophysiology of spontaneous and anticoagulationrelated ICH and presents consensus evidence for its acute management. RISK FACTORS Nonmodifiable risk factors for ICH include male gender, older age, and African or Asian ethnicity. 3-5 Cerebral amyloid angiopathy is an important risk factor in the elderly and can occur in isolation or in association with Alzheimer disease or familial apolipoprotein syndromes. 11,12 Amyloid angiopathy usually results in lobar
doi:10.1213/ane.0b013e3181d568c8 pmid:20332192 fatcat:xm6zzhflfvebdjpo5llupgodu4