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

Table of Contents

 

About This Issue

Intracerebral hemorrhage (ICH) is the deadliest form of acute stroke and spontaneous ICH accounts for up to 30% of worldwide stroke cases each year. The initial presentation of patients with ICH is similar to that of other stroke patients, necessitating swift recognition, imaging, and assessment. Emergency department management focuses on reducing blood pressure, managing intracranial hypertension, reversing coagulopathies, and identifying the patients who require urgent surgical decompression. In this issue, you will learn:

The clinical presentation of ICH, and which characteristics can help to distinguish ICH from acute ischemic stroke before imaging is obtained.

The etiologies associated with primary and secondary ICH.

The elements of the history and physical examination, including clinical scoring systems, that are most important is assessing a patient with ICH.

The utility of various imaging modalities in the management of ICH, including noncontract CT, CTA, CTV, and MRI.

How to identify and treat patients with increased intracranial pressure in the setting of ICH.

Current recommendations for managing elevated blood pressure in patients with ICH.

How to reverse coagulopathies in ICH patients who are taking various anticoagulant or antithrombotic agents.

Special considerations for management of ICH in pregnant patients and pediatric patients.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Intracerebral Hemorrhage Classification
      1. Primary Intracerebral Hemorrhage
         • Cerebral Amyloid Angiopathy
         • Hypertensive Intracerebral Hemorrhage
      2. Secondary Intracerebral Hemorrhage
   2. Cerebellar Hemorrhage
   3. Hematoma Expansion and Swelling
7. Differential Diagnosis
   1. Intracerebral Hemorrhage Versus Acute Ischemic Stroke
   2. Hyperdensities on Computed Tomography
8. Prehospital Notification and Care
9. Emergency Department Evaluation
   1. Initial Stabilization
   2. History
   3. Physical Examination
   4. Standardized Neurologic Scoring
10. Diagnostic Studies
    1. Imaging Studies
       1. Computed Tomography
       2. Computed Tomography Angiography and Computed Tomography Venography
       3. Magnetic Resonance Imaging
       4. Magnetic Resonance Angiography
       5. Cerebral Angiogram
       6. Electrocardiogram
       7. Chest X-Ray
       8. Reimaging
    2. Laboratory Studies
11. Medical and Pharmacological Management
    1. Reversal of Coagulopathies
       1. Vitamin K Antagonists
       2. Direct Oral Anticoagulants
       3. Factor Xa Inhibitors
       4. Dabigatran
       5. Heparin and Low-Molecular-Weight Heparin
    2. Blood Pressure Management
    3. Management of Suspected Elevated Intracranial Pressure
       1. Risk for Developing Increased Intracranial Pressure
       2. Optic Nerve Sheath Diameter
       3. Intubation and Sedation
       4. Osmotherapy
    4. Neurosurgical Interventions
       1. External Ventricular Drain
       2. Hematoma Evacuation and Ongoing Trials
12. Clinical Grading Scales
    1. ICH Score
    2. FUNC Score
13. Prognostics and Discussions with Families
14. Special Populations
    1. Intracerebral Hemorrhage in Pregnancy
    2. Intracerebral Hemorrhage in Pediatric Patients
15. Disposition
16. Controversies
    1. Platelet Transfusion
    2. Antiseizure Prophylaxis
17. Risk Management Pitfalls in Emergency Department Management of Intracerebral Hemorrhage
18. Case Conclusions
19. Clinical Pathway for Identification and Management of Intracerebral Hemorrhage in the Emergency Department
20. Tables and Figures
21. References

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?

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Clinical Pathway for Identification and Management of Intracerebral Hemorrhage in the Emergency Department

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282-e361. (Guidelines) DOI: 10.1161/STR.0000000000000407

2. * McGurgan IJ, Ziai WC, Werring DJ, et al. Acute intracerebral haemorrhage: diagnosis and management. Pract Neurol. 2020;21(2):128-136. (Review article) DOI: 10.1136/practneurol-2020-002763

3. * Rajashekar D, Liang JW. Intracerebral hemorrhage. StatPearls. StatPearls Publishing. Updated February 6, 2023. Accessed July 1, 2023. (Online textbook chapter)

19. * Lam AM, Singh V, O’Meara AMI. Emergency neurological life support: fourth edition, updates in the approach to early management of a neurological emergency: intracerebral hemorrhage. Neurocrit Care. 2020;32(2):636-640. DOI: 10.1007/s12028-019-00810-8 (Clinical protocol)

39. * Zimmermann LL, Tran DS, Lovett ME, et al. Emergency neurological life support: fourth edition, updates in the approach to early management of a neurological emergency: traumatic brain injury. Neurocrit Care. 2020;32(2):636-640. DOI: 10.1007/s12028-019-00810-8 (Clinical protocol)

48. * Peters NA, Farrell LB, Smith JP. Hyperosmolar therapy for the treatment of cerebral edema. US Pharmacist. 2018:43(1)HS-8-HS-11. Accessed July 1, 2023. (Review article)

51. * Kellner CP, Schupper AJ, Mocco J. Surgical evacuation of intracerebral hemorrhage: the potential importance of timing. Stroke. 2021;52(10):3391-3398. (Review article) DOI: 10.1161/STROKEAHA.121.032238

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Keywords: intracerebral hemorrhage, ICH, cerebral amyloid angiopathy, CAA, elevated intracranial pressure, ICP, primary ICH, secondary ICH, hypertensive, hypertension, hematoma, NIHSS, ABC/2, spot sign, anticoagulation, antithrombotic, reversal, coagulopathies, DOAC, LMWH, optic nerve sheath, osmotherapy, external ventricular drain, EVD, evacuation, FUNC