Neuro - ICH Flashcards
What is an intracerebral haemorrhage?
Acute extravasation of blood into the brain parenchyma.| It accounts for 10-30% of all strokes, but carries a high mortality.
What are the causes of intracerebral haemorrhage?
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
How should blood pressure be managed in patients with ICH?
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.
How would you manage a comatose patient with suspected ICH?
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 drainageC: - target BP 130-140mmHg unless within first hour unless structural cause found. - IV antihypertensives to control BPD: - monitor pupils - prompt imaging to confirm diagnosis and cause - ensure adequate CPP - Neurosurgical opinion if appropriateE: - Normothermia - normoglycaemia - reverse anticoagulation/coagulopathy (e.g. IV vit K and PCC - INCH trial demonstrated benefit of PCC over FFP) - no role for steroids
Is there a role for prophylactic anti-epilepsy medicine in ICH?
No, but seizures should be treated promptly.
What is the role of surgery in ICH?
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.
