Current management of spontaneous intracerebral haemorrhage

• Published in: Stroke and vascular neurology Vol. 2; no. 1; pp. 21 - 29
• Main Authors: Dastur, Cyrus K, Yu, Wengui
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 01.03.2017; BMJ Publishing Group
• Subjects: Antihypertensive Agents - adverse effects; Antihypertensive Agents - therapeutic use; Antihypertensives; Blood Coagulation - drug effects; Blood pressure; Blood Pressure - drug effects; Clinical Decision-Making; Combined Modality Therapy; Consciousness; Drug abuse; Early Diagnosis; Fibrinolytic Agents - therapeutic use; Fluid Therapy - adverse effects; Fluid Therapy - mortality; Hemorrhagic Stroke - diagnostic imaging; Hemorrhagic Stroke - mortality; Hemorrhagic Stroke - physiopathology; Hemorrhagic Stroke - therapy; Humans; Hydrocephalus; Hypertension; Intracranial Hemorrhage, Hypertensive - diagnostic imaging; Intracranial Hemorrhage, Hypertensive - mortality; Intracranial Hemorrhage, Hypertensive - physiopathology; Intracranial Hemorrhage, Hypertensive - therapy; Ischemia; Medical imaging; Mortality; Neurosurgical Procedures - adverse effects; Neurosurgical Procedures - mortality; Patients; Platelet Transfusion - adverse effects; Platelet Transfusion - mortality; Review; Risk Factors; Stroke; Substance abuse treatment; Treatment Outcome; Intracranial Pressure; CT; Hydrocephalus; MRI; Hemorrhage
• ISSN: 2059-8688; 2059-8696; 2059-8696
• DOI: 10.1136/svn-2016-000047

Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. Uncontrolled hypertension (HTN) is the most common cause of spontaneous ICH. Recent advances in neuroimaging, organised stroke care, dedicated Neuro-ICUs, medical and surgical management have improved the management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering of systolic blood pressure to <140 mm Hg is proven safe by two recent randomised trials. Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of haematoma. In patients with small haematoma without significant mass effect, there is no indication for routine use of mannitol or hypertonic saline (HTS). However, for patients with large ICH (volume > 30 cbic centmetre) or symptomatic perihaematoma oedema, it may be beneficial to keep serum sodium level at 140–150 mEq/L for 7–10 days to minimise oedema expansion and mass effect. Mannitol and HTS can be used emergently for worsening cerebral oedema, elevated intracranial pressure (ICP) or pending herniation. HTS should be administered via central line as continuous infusion (3%) or bolus (23.4%). Ventriculostomy is indicated for patients with severe intraventricular haemorrhage, hydrocephalus or elevated ICP. Patients with large cerebellar or temporal ICH may benefit from emergent haematoma evacuation. It is important to start intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for prophylaxis of venous thromboembolism. There is no benefit for seizure prophylaxis or aggressive management of fever or hyperglycaemia. Early aggressive comprehensive care may improve survival and functional recovery.