Intracerebral haemorrhage

Question 1

What is an intracerebral haemorrhage?

Answer 1

Acute extravasation of blood into the brain parenchyma.

It accounts for 10-30% of all strokes, but carries a high mortality.

Question 2

What are the causes of intracerebral haemorrhage?

Answer 2

Causes can be classified based on aetiology:

1. Hypertension (60-70%) - common locations include caudate, thalamus, pons, cerebellum
2. Amyloidosis (CAA) (15%)
3. Haemorrhage into a tumour
4. Haemorrhage into an infarct
5. Traumatic
6. Vasculitis
7. Coagulopathy/warfarin

Question 3

How should blood pressure be managed in patients with ICH?

Answer 3

Balance between maintaining adequate cerebral perfusion and not worsening bleeding/blood load.

2019 NICE guidance:
Aim for a systolic target of 130-140mmHg within 1 hour of treatment and for 7 days for:
- those presenting within 6 hours with a BP 150-200
- those presenting beyond 6 hours who have a BP >220

Those not recommended for rapid lowering are:

• those with underlying structural cause (e.g. AVM, aneurysm, tumour)
• GCS <6
• those not expected to survive
• those going for early neurosurgery
• if condition deteriorates on BP lowering

INTERACT2 trial and ATACH-2 trial demonstrated no detriment in outcomes from BP lowering.

Question 4

How would you manage a comatose patient with suspected ICH?

Answer 4

Resuscitation using an ABCDE approach focusing on:

A&B:
- intubation and ventilation if GCS <8 or falling to:
- pO2 >10, pCO2 4.5-5.0
- avoid tape pressure on cerebral venous drainage
C:
- target BP 130-140mmHg unless within first hour unless structural cause found.
- IV antihypertensives to control BP
D:
- monitor pupils
- prompt imaging to confirm diagnosis and cause
- ensure adequate CPP
- Neurosurgical opinion if appropriate
E:
- Normothermia
- normoglycaemia
- reverse anticoagulation/coagulopathy (e.g. IV vit K and PCC - INCH trial demonstrated benefit of PCC over FFP)
- no role for steroids

Question 5

Is there a role for prophylactic anti-epilepsy medicine in ICH?

Answer 5

No, but seizures should be treated promptly.

Question 6

What is the role of surgery in ICH?

Answer 6

STITCH trial showed no benefit of early (within 24hrs) surgery compared to conservative management.
STITCH II trial showed earlier surgery (<12 hours) in those with a predicted poor prognosis did better than conservative management, but did not affect overall death or disability at 6 months.