Intracranial Hemorrhage (ICH)
Not all head bleeds are the same - William Shyy MD and Debbie Yi Madhok MD
image by: Pop Med
HWN Recommends
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).
Primary Intracranial Hemorrhages
Primary ICHs include both intraventricular and intraparenchymal bleeds. The majority are due to severe hypertension and are localized to the cerebellum, brainstem, and midbrain. Other etiologies include aneurysm and tumor. Up to 30% of these cases expand within the first 3 hours of onset, which is why treatment guidelines include a systolic blood pressure (SBP) goal of <140-180 mmHg. This is often achieved with an IV infusion of a vasodilator, such as nicardipine or nitroprusside.…
Resources
Critical Intracranial Hemorrhage: Pearls and Pitfalls in Evaluation and Management
How does ICH present? Unlike subarachnoid hemorrhage, symptoms are not classically maximal at onset. Headache and nausea/ vomiting only occur in about half of cases, and when they do they are typically gradual in onset rather than “thunderclap.” Patients with ICH may present identically to those with ischemic stroke, and these two processes cannot be reliably differentiated from each other without imaging.
Fall on Thinners: Management of Traumatic ICH in the ED
The official recommendation from the Neurocritical Care Society is to NOT transfuse platelets for patients on antiplatelet agents unless they are undergoing a neurosurgical procedure. DDAVP (0.4 mcg/kg dose IV) may be used for reversal of aspirin and clopidogrel, but is not effective for ticagrelor..
An Approach to Intracranial Hemorrhage
Indications for surgical intervention are posterior fossa, intraventricular hemorrhage, and occasional supratentorial.
Cracking Skulls: When is Neurosurgical Intervention Helpful for ICH?
There is weak evidence that neurosurgical interventions offer benefit in sICH. We may wring our hands when our consultants say no acute interventions are required, but their inertia is not unfounded. Patients who suffer sICH are at high risk of death and poor functional status, and craniotomy is a morbid procedure.
Intracranial Hemorrhage in Children An Evolving Spectrum
Intracranial hemorrhage (ICH) in children often causes death or lifelong disability. In previous reports of pediatric ICH, the most common underlying causes for hemorrhage were intracranial vascular anomalies such as arteriovenous malformations (AVMs). However, contemporary imaging techniques have aided the detection of intracranial lesions, so the identification of ICHs may have increased compared with earlier studies.
Intracranial Hemorrhage in Older Adults: Implications for Fall Risk Assessment and Prevention
Among the worst outcomes from a fall are traumatic brain injury (TBI) and intracranial hemorrhage (ICH). TBI in older patients is due to falls in 70% of cases and increases to 85% in patients older than 85 years.
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.
The critical care management of spontaneous intracranial hemorrhage: a contemporary review
The most important modifiable risk factor in spontaneous ICH is chronic arterial hypertension.
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.
SAEM
All intracranial hemorrhages (ICH) share some classic clinical features. Common presenting symptoms include headache, nausea, vomiting, confusion, somnolence, or seizure. There is a wide clinical spectrum: patients may be alert and conversant, or moribund. In elderly, alcoholic, and anticoagulated patients, even minor head trauma can result in devastating intracranial bleeding. Despite these commonalities, there can be differences in the presentation of the four types of ICH,
Traumatic Brain Injury (TBI)
TBI is one of the leading causes of mortality and morbidity following trauma. Since younger patients are often involved, this causes a large person-year burden of morbidity.
SAEM
All intracranial hemorrhages (ICH) share some classic clinical features. Common presenting symptoms include headache, nausea, vomiting, confusion, somnolence, or seizure. There is a wide clinical spectrum: patients may be alert and conversant, or moribund. In elderly, alcoholic, and anticoagulated patients, even minor head trauma can result in devastating intracranial bleeding.
Introducing Stitches!
Your Path to Meaningful Connections in the World of Health and Medicine
Connect, Collaborate, and Engage!
Coming Soon - Stitches, the innovative chat app from the creators of HWN. Join meaningful conversations on health and medical topics. Share text, images, and videos seamlessly. Connect directly within HWN's topic pages and articles.