Emergency Department Management of Acute Intracerebral Hemorrhage - Stroke EXTRA Supplement (Stroke CME and Pharmacology CME) -

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Delivery Method:	Online
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Publication Date: July 2023 (Volume 25, Supplement 07)

CME Credits: 4 AMA PRA Category 1 Credits™ and 4 AOA Category 2-B CME credits. CME expires 07/20/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke and .5 Pharmacology credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Acute intracerebral hemorrhage accounts for only a small portion of all stroke presentations, but often leads to a high rate of morbidity and mortality. The presentation of patients with ICH is often similar to other stroke patients and requires rapid recognition, imaging, and evaluation. Treatment begins in the emergency department and focuses on correction of abnormal coagulopathies, blood pressure reduction, emergent treatment of intracranial hypertension, and recognition of those in need of urgent surgical decompression. Patients should be admitted to capable critical care units, with expertise in neurocritical care if available. This review presents evidence-based recommendations for the emergency department identification and management of patients with ICH.

Case Presentations

A 63-year-old man with uncontrolled hypertension and diabetes mellitus arrives in the ED...

• The patient reports that he developed acute hemiplegia and numbness of his left arm and left leg while eating dinner with his family earlier that evening.
• You quickly assess his airway and vital signs and determine that it is safe to send him for a CT scan.
• The CT scan reveals a right basal ganglia hemorrhage with slight midline shift. A CT angiogram of the head and neck does not show vascular malformation, and there is no spot sign.
• Should you consider evacuation? What are the blood pressure goals? Should imaging be repeated and if so, when?

An obtunded 55-year-old man is brought in from an acute rehabilitation facility…

• The patient was engaged in physical therapy when he suddenly developed dizziness, nausea, vomiting, and then “passed out,” according to the rehab facility staff.
• Documentation from the facility notes that the patient is taking warfarin.
• On your quick assessment, you note that he is not opening his eyes or responding to verbal stimulus. He is withdrawing to painful stimulation and grimacing. His pupils are sluggishly reactive.
• Given the concerning examination, you perform rapid sequence intubation and then obtain a CT head, which shows a left cerebellar hemorrhage with edema causing significant mass effect/compression of the fourth ventricle and subsequent hydrocephalus.
• While you wait for neurosurgery to take the patient to the operating room as a category 1, what additional steps should you take, if any? Should you administer medication? Are ventilator adjustments needed?

A 95-year-old woman is brought to the ED after being found in bed unable to get up…

• The patient was previously mobile and living independently. Her last known normal was the night prior.
• She has a left gaze deviation, facial droop, global aphasia, and total right hemiplegia.
• She is alert and is stable, so you send her for imaging, where she is found to have a large left middle cerebral artery-territory hemorrhage with 6-mm midline shift.
• The patient's is accompanied by her daughter, who says that she has paperwork supporting that her mother would not want heroic measures or surgeries if it meant a loss in quality of life.
• What are the differential diagnoses for this presentation and these imaging findings? What further medical interventions could be offered to this patient?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.