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Emergency Management of Intracerebral Hemorrhage – The Golden Hour

There exists a kind of self-fulfilling prognostic pessimism when it comes to ICH. And this pessimism sometimes leads to less than optimal care in patients who otherwise might have had a reasonably good outcome if they were managed aggressively. Despite the poor prognosis of these patients overall, there is some evidence to suggest that early aggressive medical management may improve outcomes.

As such, the skill with which you manage your patient with ICH in those first few hours could be the most important determinant of their outcome. In this Golden Hour you have a chance to prevent hematoma expansion, stabilize intracerebral perfusion and give your patient the best chance of survival…

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  Intracerebral Hemorrhage (ICH) Score

Please note that the ICH score is primarily used as a clinical grading scale and communication tool. It is not meant to provide prognostic information, and should not be used as a primary means to predict the outcomes of patients with ICH.

  Glasgow Coma Scale/Score

Note that this calculator has been updated as of May 2019 in order to add more supporting references and to distinguish between the Glasgow Coma Score (total score, only applicable when all three components are testable) and the Glasgow Coma Scale (component scores, applicable if any of three components is not testable).

Articles of Interest

BP Control

If you shoot for a systolic Bp <180 mm, then you'll often end up with a systolic Bp around ~140-160 mm, which is good... Despite repeated and well-powered trials, there is no evidence that more intensive blood pressure control can improve hematoma size. If lower blood pressure isn't reducing hematoma size, then it may be only harming patients due to hypoperfusion of compressed penumbra tissue.

Treating Blood Pressure in Intracranial Hemorrhage

So what’s the right thing to do? If data suggests that lowering may not be as beneficial, what should the target blood pressure be? Target SBP 140-160 mmHg is a reasonable target

Five Tips for Managing Intracerebral Hemorrhage

For those ICH patients with Glasgow Coma Scale (GCS) scores >7, the current recommendation to lower BP to 140/80 is unlikely to be harmful but may be minimally beneficial. However, two recent trials have failed to definitively show benefit.

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Spontaneous ICH is a neurological emergency associated with high mortality and morbidity. Key management issues include prompt etiologic diagnosis, reversal of anticoagulation, consideration of surgical management, and control of blood pressure. The clinical scenario and local practice will influence choice of therapeutic environment.

Blood pressure management in acute intracerebral hemorrhage

Avoiding hypertension could possibly limit expansion of hematoma. However, there is mixed evidence regarding whether or not there are clinically significant differences in hematoma expansion with aggressive blood pressure control

Blood Pressure Management in Spontaneous Intracerebral Hemorrhage

In 2010, the AHA guidelines for management of ICH suggested that in patients with significantly elevated blood pressure (SBP > 180 or MAP > 130), a “modest reduction” in BP should be considered (SBP < 160, MAP < 110). This arbitrary BP goal was challenged in 2013 by the publication of the INTERACT2 trial. This seminal trial compared traditional BP management to more intensive BP lowering (goal SBP < 140 mm Hg within one hour), and found no statistically significant improvement in the primary outcome of functional status.

Challenges and controversies in the medical management of primary and antithrombotic-related intracerebral hemorrhage

Intracerebral hemorrhage (ICH) represents 10—15% of all cerebrovascular events, and is associated with substantial morbidity and mortality. In contrast to ischemic cerebrovascular disease in which acute therapies have proven beneficial, ICH remains a more elusive condition to treat, and no surgical procedure has proven to be beneficial.

Current management of spontaneous intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. Uncontrolled hypertension (HTN) is the most common cause of spontaneous ICH. Recent advances in neuroimaging, organised stroke care, dedicated Neuro-ICUs, medical and surgical management have improved the management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering of systolic blood pressure to <140 mm Hg is proven safe by two recent randomised trials.

EM@3AM: Spontaneous Intracerebral Hemorrhage

Blood Pressure Reduction. Current guidelines suggest that for: SBP>200 or MAP>150 treat with continuous IV infusion of BP lowering agent. SBP>180 or MAP>130 with evidence of increased intracranial pressure, treat with continuous IV infusion or intermittent doses to preserve cerebral perfusion pressure to >60-80 mmHg. SBP>180 or MAP>130 with no evidence of increased intracranial pressure, treat to goal BP of approximately 160/90 or MAP of 110. Has also been shown that SBP may be lowered to 140 with no increase in adverse events. Suggested agents selected for short half-lives and ease of titratability include: Labetalol- 10-20 mg IV over 1-2 minutes. Repeat dose every 10-15 mintues to a maximum of 300 mg. Esmolol- 1 mg/kg bolus over 30 seconds. Followed by 150 mcg/kg/min continuous infusion (may titrate up to 300 mcg/kg/min). Nicardipine- continuous infusion starting at 5 mg/hr to maximum of 15 mg/hr. Avoid hypotension, as SBP < 120 mm Hg is associated with worse outcomes.

EMNerd-The Case of the Differing Perspectives

When you exclude the ill-gotten gains of INTERACT-2’s secondary analysis what you are left with is a negative trial. ATACH-2 only serves to validate these results. As it stands we have two large trials, both demonstrating that aggressive blood pressure management offers little clinical utility in patients presenting with ICH.

Management of brainstem haemorrhages

Primary brainstem haemorrhages remain associated with poor outcomes compared to other forms of spontaneous ICH. Negative prognostic factors are coma on admission, the need for mechanical ventilation, haematoma volume and the ventral extension of the haemorrhage.

Management of Post-tPA Intracerebral Hemorrhage

Unfortunately for patients with symptomatic intracerebral hemorrhage (sICH) after receiving tPA, there is a paucity of data to support any one therapeutic intervention.

Optimal Blood Pressure After Intracerebral Hemorrhage

The optimal management of acute hypertension after ICH remains undefined. Large randomized trials did not provide consistent evidence that aiming for one particular BP target is broadly beneficial and informed us that very rapid and aggressive BP reduction can be harmful. Meanwhile, exploratory analyses like the one reported by Chung et al indicate that excessive BP fluctuations portend poor outcome and suggest that avoiding these fluctuations could represent a valid therapeutic target.

Outcomes of Intensive Systolic Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure

This post hoc analysis of a randomized clinical trial showed higher rates of neurological deterioration and no evidence of reducing hematoma expansion at 24 hours or death or severe disability at 90 days in those who underwent intensive systolic blood pressure reduction.

Tranexamic Acid for Acute Intracerebral Hemorrhage

In conclusion, this large trial demonstrated that tranexamic acid in acute ICH is safe and associated with a minimal reduction in the extent of bleeding, without a significant impact on ICH outcome.

Update on the ED Management of Intracranial Hemorrhage: Not All Head Bleeds Are the Same

Robust and comprehensive studies now support specific management guidelines for patients presenting with different intracranial hemorrhages (ICH). From the Emergency Department perspective, the primary dilemmas involve specific blood pressure goals and whether seizure prophylaxis with phenytoin is necessary. The Brain Trauma Foundation provides an excellent summary of the current guidelines.

Resources

ATACH II

In patients with spontaneous intra-cranial hemorrhage with volume of <60 cm3 and a Glasgow Coma Scale (GCS) score of >4/15, there is no differences in mortality or morbidity in patients receiving intensive blood pressure control compared to standard blood pressure control.

INTERACT 2

In patients with intracerebral hemorrhage intensive blood pressure lowering did not reduce the risk of death or severe disability.