Vomiting is a very important sign regarding intraparenchymal hemorrhage – almost 50% will vomit as opposed to only 2% of patients with ICA, MCA, or ACA ischemia [Neurology 28: 754, 1978]. Rebleeding is common in IPH patients, and is most likely within 6-24 hours. For this reason, blood pressure should be controlled rigidly – always take into account a history of hypertension, but in general, keeping SBP < 130 mm Hg and CPP > 70 mm Hg is reasonable [Stroke 30: 905, 1999]. In order to control ICP, the AHA guidelines support ICP monitoring for GCS < 9 or neurologic deterioration [Stroke 30: 905, 1999]. Also, seizures will occur in 10-15% of these patients, however almost all of them will be at the outset, rarely occurring afterward [Neurology 38: 1363, 1988]
Activated Recombinant Factor VII in ICH
399 patients with ICH diagnosed by CT within three hours after onset were randomized to receive placebo or 40 μg/kg, 80 ug/kg, or 160 ug/kg rFVIIa within one hour after the baseline scan. Hematoma volume increased more in the placebo group than in the rFVIIa groups (29% in the placebo group vs. 16%, 14%, and 11%, p=0.01 overall). Growth in the volume of intracerebral hemorrhage was reduced by 3.3 ml, 4.5 ml, and 5.8 ml (p=0.01). 69% of placebo-treated patients died or were severely disabled (modified Rankin Scale score of 4 to 6), as compared with 55%, 49%, and 54% of the rFVIIa patients, respectively (p=0.004 overall). Mortality at 90 days was 29% for patients who received placebo, as compared with 18% in the three rFVIIa groups combined (p=0.02). Serious thromboembolic adverse events, mainly myocardial or cerebral infarction, occurred in 7% of rFVIIa-treated patients, as compared with 2 percent of those given placebo (p=0.12) [NEJM 352: 777, 2005]
2010 AHA/ASA Guidelines
In July 2010, the AHA and ASA released updated guidelines for the care of patients with ICH [Morgenstern LB et al. American Heart Association/American Stroke Association Council on Stroke. 2010]. Regarding the new guidelines, the committee noted that “the clear message that we want to send with this guideline is that intracerebral hemorrhage is a very treatable disorder.
Important points from the guidelines include:
- For the emergency diagnosis and assessment of ICH, the committee’s recommendation for rapid neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is unchanged, but they have added a new recommendation that other imaging modalities, such as CT angiography or contrast-enhanced CT, may be considered to help identify patients at risk for hematoma expansion or to evaluate for underlying structural lesions, such as vascular malformations and tumors.
- Under medical treatment of ICH, 1 new recommendation is that patients with a severe coagulation factor deficiency or severe thrombocytopenia should received appropriate factor replacement therapy or platelets, respectively. Another revision in this section recommends patients with ICH whose international normalized ratio (INR) is elevated due to the use of oral anticoagulants should have warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K.
- Among new recommendations for inpatient management and prevention of secondary brain injury, the writing committee has included new and revised recommendations that glucose be monitored and normoglycemia maintained and that clinical seizures and those with depressed mental status found to have seizures on electroencephalograms should be treated with antiepileptic drugs. Prophylactic anticonvulsants are not recommended.
- Under procedures and surgery, 1 new recommendation is that patients with a Glasgow Coma Scale score of less than 8, as well as those with clinical evidence of transtentorial herniation, or those with significant intraventricular hemorrhage or hydrocephalus might be considered for intracranial pressure monitoring and treatment, they write. It may be “reasonable” to maintain a cerebral perfusion pressure of 50 to 70 mm Hg, depending on the status of cerebral autoregulation. Ventricular drainage as treatment for hydrocephalus is also seen as reasonable in patients with a decreased level of consciousness.
- Results of the Clot Lysis: Evaluating Accelerated Resolution of IVH (CLEAR-IVH) open-label trial of intraventricular recombinant tissue plasminogen activator in IVH suggested a low complication rate, but the efficacy and safety of this treatment are “uncertain and considered investigational,” they note.
- In terms of clot removal, the committee has provided a new recommendation that for most patients with ICH, the usefulness of surgery is “uncertain.” Exceptions to this conclusion are patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction, who should undergo surgical removal of the hemorrhage as soon as possible, the study authors note. A new recommendation is that initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended.