Intracerebral Haemorrhage

Question 1

A 54 year old man with hypertension presents with the sudden onset of severe right sided headache, nausea, committing and left sided weakness. He is drowsy but orientated and coherent when roused. He has no neck stiffness of papilloedema but has a dense left hemiplegia and extensor plantar response. He is in sinus rhythm with a BP of 230/130 mmHg. How would you manage him?

Answer 1

Impression
Features of this stem are consistent with a stroke given the left-sided hemiplegia, and there are features of raised ICP given nausea and vomiting + headache. In the setting of significant hypertension, I am concerned this is an ischaemic stroke, with risk of re-bleeding and vascular spasm. This is a medical emergency and I would start this patient on the stroke work-up pathway.

Other DDX to consider include;

• Vascular: SAH, ischaemic stroke, AVM
• Infective: meningitis, encephalitis
• Neoplastic: SOL, neoplastic haemorrhage
• Mimics: hemiplegic migraine, todds paresis

Goals

• Stroke pathway for initial assessment and workup, involve senior help
• definitive management according to aetiology of symptoms; ?for retrieval and neurosurg intervention for craniotomy and evacuation

Question 2

ICH - Assessment

Answer 2

Assessment
- Call for senior assistance
- Run A to E with concurrent Hx and Ex, main concern is current hypertension as could precipitate a further bleed so would like to manage
A - Patent, maintaining, tube pending GCS, suction for any vomitus
B - RR/SP02 monitoring, supplemental as req.
C - BP/HR monitoring. 2xIVC large bore cannulas. Initial bloods (VBG, BSL, coags, FBC, CRP, UEC, LFT). Administer IV nifedipine to reduce risk of vasospasm and ischaemic extension, also aim to lower BP to <140 mmHg lower than presentation with labetalol infusion (conjecture in the current literature). Reverse any anticoagulation. Imaging - non-con CTB +/- angio/perfusion scans.
D - GCS, PEARL,
EFG -

Question 3

ICH - History

Answer 3

History

• MIST AMPLE initially then;
• PC: onset, timing of neurological symptoms, nature of headache, location, MOI - head trauma sustained?
• cardio risk factors: HTN (and previous control), diabetes, previous stroke/MI, fam history
• medications + allergies
• contraindications for thrombolysis (recent ICH, recent MI, etc)

Question 4

ICH - Examination

Answer 4

Examination

• general appearance + vitals
• Neuro exam: weakness, reduced sensation
• Speech path for swallow assessment - ?aspiration risk and +/- NBM +/- NGT

Question 5

ICH - Investigations

Answer 5

Investigations
Key/diagnostic
- non-con CTB - hyper density within brain parenchyma with surrounding hypo density reflecting cerebral oedema
- MRI Brain for reperfusion injury

Bedside: ECG
Bloods: As per A to E
Imaging: as above

Question 6

ICH - Management

Answer 6

Management
- discuss with neurosurg for definitive treatment

Interim;

• reverse anticoagulation and cease anticoagulants/antiplatelet meds
• BP management to <140mmHg lower than presentation pressure, utilise local guidelines and senior input for regimen
• mechanical VTE prophylaxis rather than pharmacological
• telemetry
• consider prophylactic anti seizure medication

Definitive

• rapid neurosurgical craniotomy and evacuation - potentially lifesaving. however, most surgery is not helpful in ICH
• hydrocephalus management: ventricular drain, permanent VPD insertion, serial LP