ICH

Question 1

Where are the classic locations if ICH?

Answer 1

Basal ganglia
Thalamus
Pons
Cerebellum

Question 2

Surgical evacuation of a hematoma is reserved for

Answer 2

<75 years of age
Cerebellar hemorrhages
Supratentorial hemorrhages

Question 3

Pts with cerebellar hemorrhages benifit the most from clot evacuation if

Answer 3

There is displacement of the 4th ventricle
There is enlargement of the temporal horns (early obstructive hydrocephalus)
There is compression of the brainstem
Pt has decreased LOC

Question 4

Pts with supratentorial hemorrhages benefit the most from clot evacuation if

Answer 4

• The location of the clot is close to the brain surface - lobar or superficial location
• Volume >20ml with mass effect
• Decreasing LOC, drowsy but not comatose
• more likely if not in eloquent location
• Age less than or equal to 75

Question 5

Hematoma enlargement occurs:

Answer 5

• In 20-35% of all cases
• in all locations
• Usually the first few hrs after symptom onset but almost always in the first 24 hours
• May occur later in pts with coagulopathy
• Associated with worse prognosis

Question 6

What is the SPOT sign?

Answer 6

Used to risk stratify those pts who may have hematoma enlargement.
Shows contrast extravastation

Question 7

What is the goal for treating Coumadin related ICH

Answer 7

Maintain normal INR with FFP 20ml/kg and vite K

Question 8

What is the dose of Vite K for a Coumadin related ICH

Answer 8

10mg over 10 min - repeat daily X 3 days

Question 9

How do you treat heparin associated ICH

Answer 9

• Stop heparin
• CT brain
• Labs
• Type and cross
• Protamine 25 mg and check stat PTT in 10 min. If elevated give an additional 10 mg and repeat until PTT is normal

Question 10

What is the recommended BP, MAP, and time period for lowering the BP in ICH

Answer 10

BP 120-150
MAP 100-120
For the first 12-24 hrs

Question 11

Drugs to treat HTN for post ICH are

Answer 11

Nicardipine 5mg/hr and titrate up to 15mg/hr
Labetalol 10-20 mg IV bolus and repeat as needed up to 60 mg
Avoid nitroprusside

Question 12

BP must be controlled but CCP should be

Answer 12

<70 mm Hg

Question 13

Post care for ICH

Answer 13

Maintain CCP <70 mm Hg
ICP <20mm Hg
Ventricular drainage 
Maintain euvolemia and normothermia
Monitor for neurologic deterioration
Withhold all antithrombotic drugs for 2 weeks
Prevent DVT
Talk to family about outcomes 
Early disposition

Question 14

When is it recommended to start SC heparin or LMWH?

Answer 14

At least 24 hrs
Coagulation parameters have normalized
If hemiplegia wait 3-4 days before giving LMWH or unfractionated heparin

Question 15

Neurological deterioration in ICH is related to

Answer 15

Rebleeding
Hydrocephalus
Cerebral edema
Other medical problems - infection, MI, electrolyte imbalance, pulmonary emboli

Question 16

If a pt with a hemorrhagic stroke is on Coumadin how would you return them to hemostasis

Answer 16

Give PCC - prothrombin complex concentrate