Open Access ReviewCurrent management of spontaneous intracerebral haemorrhage Cyrus K Dastur, Wengui Yu To cite: Dastur CK, Yu W. ABSTRACT prevention with antihypertensive medication Current management of Intracerebral haemorrhage (ICH) is the most is likely the most effective strategy to reduce spontaneous intracerebral devastating and disabling type of stroke. Uncontrolled haemorrhage. Stroke and the burden of ICH. Although only account- hypertension (HTN) is the most common cause of ing for ∼10–15% of all stroke in the USA, Vascular Neurology 2017;00: e000047. doi:10.1136/svn- spontaneous ICH. Recent advances in neuroimaging, ICH causes a disproportionately high level of organised stroke care, dedicated Neuro-ICUs, medical 2016-000047 morbidity and mortality.7 In 2010 alone, and surgical management have improved the 62.8 million disability-associated life-years management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and (DALY) were lost compared with 39.4 million Received 10 October 2016 DALYs lost due to ischaemic stroke. Despite Accepted 8 November 2016 surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering age-standardised mortality rates from ICH of systolic blood pressure to <140 mm Hg is proven decreasing by over 25% over the last 15 years, safe by two recent randomised trials. Transfusion of 3.2 million deaths were attributed to ICH vs platelets in patients on antiplatelet therapy is not 3.3 million deaths from ischaemic stroke in indicated unless the patient is scheduled for surgical 2013 alone.7 evacuation of haematoma. In patients with small Population-based studies suggest that the haematoma without significant mass effect, there is no majority of patients with small ICH are indication for routine use of mannitol or hypertonic readily survivable with good medical care.8 saline (HTS). However, for patients with large ICH (volume > 30 cbic centmetre) or symptomatic For patients with large ICH, comprehensive perihaematoma oedema, it may be beneficial to keep multidisciplinary care is essential to minimise serum sodium level at 140–150 mEq/L for 7–10 days morbidity and mortality. Multiple studies to minimise oedema expansion and mass effect. have shown that caring for patients with ICH Mannitol and HTS can be used emergently for in dedicated neurological intensive care worsening cerebral oedema, elevated intracranial units by a specialised neurocritical care team pressure (ICP) or pending herniation. HTS should be results in significantly reduced length of stay administered via central line as continuous infusion and mortality.9–11 In recent years, numerous (3%) or bolus (23.4%). Ventriculostomy is indicated clinical trials have examined various medical for patients with severe intraventricular haemorrhage, and surgical options for ICH. This review will hydrocephalus or elevated ICP. Patients with large summarise the advances in the evaluation cerebellar or temporal ICH may benefit from emergent haematoma evacuation. It is important to start and management of ICH. intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for CLASSIFICATION prophylaxis of venous thromboembolism. There is no Spontaneous ICH is defined as intraparench- benefit for seizure prophylaxis or aggressive ymal bleeding in the absence of trauma or management of fever or hyperglycaemia. Early surgery. Common risk factors for spontan- aggressive comprehensive care may improve survival eous ICH include HTN, age, history of heavy and functional recovery. alcohol, methamphetamine or cocaine use, education at less than a high school level and genetic alleles associated with cerebral INTRODUCTION amyloid.3 4 12–14 Intracerebral haemorrhage (ICH) affects Spontaneous ICH can be classified as either >1 million people annually worldwide and is primary or secondary depending on the the deadliest and most disabling type of underlying cause. Primary ICH accounts for Department of Neurology, stroke.1 2 Uncontrolled hypertension (HTN) ∼70–80% of cases and is due to spontaneous University of California Irvine, is the most common risk factor for spontan- rupture of small vessels damaged by HTN or Irvine, California, USA eous ICH.3 4 The incidence of ICH is higher amyloid angiopathy. Primary ICH is also clas- Correspondence to in Asians, partly due to limited primary care sified by location as lobar versus non-lobar Dr Wengui Yu;
[email protected] for HTN and non-compliance.5 6 Primary and supratentorial versus infratentorial.15 Dastur CK, Yu W. Stroke and Vascular Neurology 2017;00:e000047. doi:10.1136/svn-2016-000047 1 Copyright 2017 by BMJ Publishing Group Ltd. but rarely offers additional infor- mation in the acute setting. depressed consciousness and large haemorrhages. ICH is a medical emergency requiring urgent therapy genital and acquired conditions such as vascular malfor.18–20 In addition to a prompt brainstem herniation should receive ventriculostomy. ICH. pons and cerebellum (figure 1). thalamus. pons ation of any acute deterioration in the neurological and cerebellum.00:e000047.21 22 This method of haematoma volume calcula- tion. CAA. the haemorrhages or symptomatic lobar haemorrhages. Stroke and Vascular Neurology 2017.3 16 17 (EMS). coagulation disorders. hydrocephalus and early signs of herniation. drug abuse or vascular sign’. hypertonic saline (HTS) infusion. mass effect. drug abuse and cerebral venous thrombosis.16 (A).14 requirement for an additional CT scan and greater radi- Non-lobar ICH is most often the result of long-standing ation exposure may limit its clinical utility. Yu W. subcortical white matter. and showed a rupture of these vessels. where A is maximal haema- toma diameter on the axial slice with largest haematoma area.14 Amyloid deposition in small-sized to the ‘leakage sign’. ciated with ongoing bleeding and increased mortality. Figure 1 Typical locations of hypertensive ICH are putamen cavernoma and tumour). Haematoma volume can be estimated on head CT using the ABC/2 method. thal- amus. tumours. elevated systolic blood pressures or hypoxaemia. vomiting. The intracerebral haemorrhage.5–1 g/kg or roimaging with a non-contrast head CT is highly sensi. subcortical white matter (C).1136/svn-2016-000047 . use of or more points in their Glasgow Coma Scale (GCS) after anticoagulants and thrombolytic agents. has higher sensitivity and specificity for medium-sized cortical perforators may lead to the haematoma expansion than the spot sign. their initial assessment by Emergency Medical Services litis.21 22 CT scan will reveal not only the location emergent intervention is shown in figure 2.Open Access and size of the ICH but also intraventricular extension.24 However.16 Rapid diagnosis is Intubation for airway protection is indicated in patient crucial for appropriate care and better functional out.25 In addition. clinical history and neurological examination. locations of hypertensive ICH are the putamen. 2 Dastur CK. cerebral amyloid angiopathy. CAA. Patient comes. HTN and haematoma expansion. high blood pressure resulting in lipohyalinosis of small Repeat imaging study should be considered for evalu- perforating arteries of the basal ganglia. significant association with poor outcomes. decreased level of consciousness. Delayed MRI is better utilised as an adjunct tool to aid in determin- ation of the underlying cause of the ICH (such as CAA. cerebral vascu. Early deterioration in the first few hours after with a decreased level of consciousness from intraventri- initial onset is common. while variable between examiners. Thalamic and subcortical haemorrhages often vascular abnormalities and contrast extravasation as ‘spot extend into ventricles (B and C). The Emergency tive and specific for ICH and is the key to early Department (ED) algorithm for early diagnosis and diagnosis. EMERGENT INTERVENTION Secondary ICH is associated with a number of con. risk of contrast extravasation is increased with extreme HTN. hyperosmolar therapy with mannitol 0. A Lobar ICH is commonly the result of cerebral amyloid newer technique for determining haematoma expansion. with GCS ≤8 or significant respiratory distress. rapid neu. 15–23% of patients have haema- toma expansion and neurological decline in the first several hours.23 Contrast extravasation during angiography is asso- anomaly often causes lobar haemorrhage (F). angiopathy (CAA). mass effect or and from secondary injury. The time and transportation required for MRI can be detrimental due to a high risk of deterioration during the first few hours. pons (D) and CT angiogram is very sensitive for identifying associated cerebellum (E). given that >20% of patients experience a decrease of 2 mations. leading to deep haemorrhages. breathing and circulation ICH should be suspected in any patient with severe (ABCs) is essential for preventing secondary injury from headache.25 26 EARLY DIAGNOSIS Stabilisation of airway. doi:10. often examination or for follow-up of any underlying lesion or with extension into the ventricles. B is maximal haematoma diameter perpendicular to A and C is the number of CT slices with haematoma multiplied by slice thickness (ignoring slices with <25% of haematoma area compared with the reference slice). from haematoma expansion cular haemorrhage with hydrocephalus.17 22 MRI can be as sensitive as CT in determining the pres- ence of haemorrhage. thalamus (B). resulting in asymptomatic micro.12 15 The most common vascular anomaly. has been shown to be effective for clinical decision-making. 00:e000047. prospective randomised controlled trials have Given the findings from INTERACT-2 trial. Management of HTN events (9. intracerebral haemorrhage.1±14.31 centre.0% vs 4. 2 hours were 128.1136/svn-2016-000047 3 . and ease of titration.31 Participant Intravenous calcium channel blockers (eg.8 mm Hg.27–29 ively. though aggressive blood pres- Rankin scores indicated improved functional outcomes sure reduction with continuous antihypertensive drug with intensive lowering of blood pressure. The much lower ischaemia from aggressive early blood pressure reduc. Recent studies showed no evidence of ischaemia in ATACH II trial might explain the higher incidence of the perihaematoma zone. respect- logical deterioration and poor outcomes after ICH. the 2015 showed that early lowering of SBP to <140 mm Hg is safe update to the AHA/ASA Guidelines for the without significant adversary effects. ICH.9±16 and 141. given their short half-life end points of death or disability at 90 days. doi:10. <140 mm Hg with <180 mm Hg showed no increase in acute lowering of SBP to 140 mm Hg is safe and may be adverse events in the aggressive treatment group. Yu W.0%.20 The There was no significant difference in death or severe optimum target for patients presenting with SBP disability at 90 days.30 effective for improving functional outcome. The study.31 Of note. There was no significant difference in the primary choice for early BP reduction. labetalol) are the treatment of 2015. showed a higher incidence of adverse renal potential for cerebral vasodilation and elevated Dastur CK. neuro. Stroke and Vascular Neurology 2017. minimum SBPs in the intensive treatment group in the tion. An ordinal analysis of modified >220 mm Hg is less clear. multi. Open Access Figure 2 The ED algorithm for early diagnosis and emergent intervention. there was concern about perihaematomal achieved in the INTERACT-2 trial.28 29 Two large phase III. p=0.002) in the intensive treat- Patients with ICH very often present with significantly ment than the standard treatment group.32 Nitrates should be avoided given however. The intravenous infusion and frequent monitoring is reason- Antihypertensive Treatment of Acute Cerebral able. Any clinical deterioration in association with Hemorrhage (ATACH) II trial used intravenous nicardi. Elevated systolic blood pressure mean minimum SBPs of the two groups during the first (SBP) is associated with haematoma expansion. the elevated blood pressure. adverse renal events. which were much lower than 150 and 164 mm Hg In the past.20 ≤140 mm Hg versus SBP ≤180 mm Hg.30 31 The Management of Spontaneous ICH recommend that for INTERACT-2 trial comparing early lowering of SBP to patients presenting with SBP between 150 and 200. aggressive reduction of blood pressure should lead to a pine within 3 hours of ICH onset to target SBP reassessment of the target blood pressure. nicardi- enrolment was suspended at 1000 patients in September pine) and β-blockers (eg. Unlike serum-containing symptomatic ICH are shown in figure 3. However. Though acute cially if continued haemorrhage despite first-line reversal of coagulopathy has not been clearly shown to therapies. expansion. rapid correction For patients taking Factor Xa inhibitors (eg. haemorrhages weaning off intravenous agents. dabigatran. If repeat INR 15–60 min after PCC administra- ant patients. For all patients taking vitamin K antagonists (eg. The guidelines for resistant cated for warfarin reversal in adults during acute major HTN recommend angiotensin converting enzyme inhibi.32 The CCB and ACE-I or ARB are widely (TRALI) and Transfusion Associated Cardiac Overload accepted as the first-line and second-line drugs for resist.16 a specific neutralising monoclonal antibody fragment for dabigatran. be beneficial in large randomised trials. In addition. Westlake Village. Variation in The guidelines for reversing warfarin and novel oral factor VII concentrations in PCC has led to their classifi. (or beyond in patient with renal insufficiency). Transfusion-Related Acute Lung Injury formula. tion of INR. If presenting lished guidelines for the reversal of antithrombotic within 2 hours of drug exposure. be guided by bleeding (major or intracranial) instead. arga- Spironolactone and α-/β-antagonists can be used as the troban and bivalirudin) have significantly less risk of third and fourth agents to maintain BP control while ICH than vitamin K antagonists. PCC is preferred over FFP due to more rapid correc- calcium channel blocker (CCB) and a thiazide-like diur. reversal should the agent used. Los Angeles. do occur and reversal of coagulopathy is indicated if patients may have resistant HTN due to sympathetic patient presents within 3–5 half-lives of drug exposure surge.37 It has not been PCC is an inactivated concentrate of factors II. bleeding or a need for urgent surgery.Open Access intracranial pressure (ICP).34 Approximately 12–20% of patients presenting dabigatran-associated ICH and renal insufficiency. doi:10. can bind and reverse oral and parenteral factor Xa inhi- thrombin complex concentrates (PCCs) should be bitors. is recommended in cases of haemor- rhage associated with dabigatran. kg) or activated PCC (50 units/kg) is recommended if In December 2015. is associated with haematoma or activated PCC (50 units/kg) is recommended. effective for patients with resistant HTN. randomised trial. administered intravenously for patients with INR ≥1. tions and be at risk of hypotension unless the doses of Idarucizumab (5 g intravenous divided into two doses).00:e000047.1136/svn-2016-000047 . be administrated to prevent further drug absorption. 4-factor PCC (50 units/kg) systemic disease process. Andexanet alfa is a recombinant modified factor Xa that farin).35 Whenever ICH is diag.33 Direct thrombin inhibitors (DTIs.36 If idarucizumab is REVERSAL OF COAGULOPATHIES not available. they may require fewer medica. but the choice of the third-line and fourth. therefore. or if the haemorrhage is associated with a Coagulopathy. California. rivaroxa- of coagulopathy should be considered in any potentially ban. with variable amounts of factor VII. Thiazide may cause hyponatraemia and worsen Factor VIIa (rFVIIa) has been associated with relatively cerebral oedema in patients with large haemorrhage or high thrombosis rates and should only be considered in mass effect.or 4-factor. apixaban and edoxaban.4. activated charcoal can agents in patients with ICH. The two time (aPTT) is significantly prolonged in setting of new 4 Dastur CK.4. (TACO). administration. war. Arterial line placement is Corporation. including rivaroxaban. IX and approved by the FDA for clinical use. Recombinant practice. tion shows continued INR elevation above 1. pulmon- etic at maximal tolerated doses as an optimal triplets ary oedema. and increased risk of poor outcome and Haemodialysis can also be considered in patients with death. USA). apixaban and edoxaban). the concentration of vitamin Reversal of prophylactic subcutaneous heparin should K-dependent clotting factors is ∼25 times higher than only be considered if activated partial thormboplastin plasma and can reverse coagulopathy quickly. Stroke and Vascular Neurology 2017. medications are adjusted promptly. X. nosed. Oral antihypertensive agents 3-factor products currently available in the USA are need to be started as soon as possible to control resistant Profilnine SD (Grifols Biologicals. HTN and facilitate the transition of care from ICU to California. Yu W. spironolactone was shown to be very Jehovah’s witness). PCCs are Reversal of unfractionated heparin is recommended lyophilised and can be reconstituted quickly for timely for patients who develop ICH while on heparin infusion. and low-molecular-weight heparin. the Neurocritical Care Society the haemorrhage occurred within 3–5 half-lives of drug together with the Society of Critical Care Medicine pub. During acute phase. lower volume and risk of infection. tors (ACE-I) or angiotensin receptor blockers (ARB). espe- with ICH are taking oral anticoagulants. A few weeks later. The method of reversal will depend on treatment for these patients. consider line antihypertensive agents varies greatly in real-world further correction with 2–4 units FFP. vitamin K 10 mg and 3-factor or 4-factor pro. exposure (or in context of liver failure). 4-factor PCC (50 units/ salvageable patient. products such as fresh frozen plasma (FFP). whether medication-induced or due to a DTI other than dabigatran. Kcentra recommended to optimise blood pressure monitoring (Beriplex outside the USA) is the first 4-factor PCC indi- and medication titration. USA) and Bebulin VH (Baxter Healthcare long-term management. any antithrombotic agent should be immediately Laboratory testing is unlikely to be helpful in guiding discontinued. anticoagulants (NOAC) coagulopathies in patients with cation as either 3. It should be used with caution. In a recent patients who will not accept blood products (eg. eg. Open Access Figure 3 The guidelines for reversing warfarin and NOAC coagulopathies in patients with symptomatic ICH. to platelet transfusion and standard care. an antifibrinolytic agent (tranexamic hydrocephalus or evidence of transtentorial hernia- acid 10–15 mg/kg intravenous or ε-aminocaproic acid tion.35 mended for reversal in patients with ICH. cal procedure. kg intravenous once) can be considered in ICH asso- danaparoid was not reversed with protamine. inhibitor-associated ICH who will undergo a neurosurgi- ine per every 1 mg of enoxaparin should be administered. but can be sion is not recommended for non-steroidal anti-inflam- considered if protamine contraindicated. If the level of fibrinogen is <150 mg/dL GCS and an independent predictor of poor outcome. haemorrhage volume or neuro- 100 units of heparin given in past 2–3 hours.38 For enoxaparin administered within past 8 hours. outcomes. though none pidogrel and abciximab).00:e000047.20 Elevated ICP (>20 mm Hg) should be treated 4–5 g intravenous) can be considered. consider additional cryoprecipi. aspirin. Platelet trans- nadroparin and tinzaparin) is also recommended only if fusion seems inferior to standard care for patients taking receiving therapeutic doses. open-label rando- 50 mg) should be utilised and repeated at half of the mised trial at 60 hospitals in the Netherlands. therefore. 0. 190 patients with ICH on antiplatelet therapy Reversal of low-molecular-weight heparin (low molecular for at least 7 days prior to ICH were randomly assigned weight heparin (LMWH). dalteparin.5 mg of protam. Platelet function testing prior to platelet For the reversal of dalteparin. In a multicentre.4 µg/ USA. ciated with cyclooxygenase (COX) inhibitors or ADP aPCC or FFP. maximum logical examination. platelet transfusion should be avoided. Yu W. doi:10. intracerebral haemorrhage. cerebrospinal fluid drainage or sedation. with aspirin. danaparoid) are not available in the inhibitor-related ICH. dose if continued bleeding or patient has renal insuffi. receptor inhibitors. If cryoprecipitate is contraindicated considered in any patient with GCS ≤ 8. antiplatelet therapy before ICH. Desmopressin (ddAVP) (0. significant IVH.39 post cryoprecipitate use. or unavailable. This can be repeated at half of the initial limits or patient has documented antiplatelet resistance. regardless of antiplatelet agent. nadroparin and tinzaparin. It is associated with lower be considered. but are used in other countries. 10 units of cryoprecipitate may 45% of patients with ICH. recombinant tissue plasminogen Intraventricular haemorrhage (IVH) occurs in up to activator (rtPA)) reversal. up to results available. France. PCC. 1 mg of Platelet transfusion should be considered for patients protamine per every 1 mg of enoxaparin should be admi. UK and initial dose if repeat aPTT remains elevated. For patients taking antiplatelet agents (eg.or adenosine diphosphate receptor (ADP) nistered. matory drugs (NSAIDs) or glycoprotein (GP) IIb/IIA Heparinoids (eg. If platelet function is within normal maximum 50 mg. Intravenous protamine (1 mg per every platelet function testing. these agents are not recom. Stroke and Vascular Neurology 2017. haemorrhage. External ventricular drain (EVD) placement should be tate administration. clo.12 Dastur CK. hydrocephalus For thrombolytic (eg. rFVIIa is generally not recommended. ICH. If enoxaparin given 8–12 hours. eg. In ex vivo studies. transfusion should be performed if possible and timely dose 1 mg per every 100 anti-Xa units of LMWH. with hyperosmolar therapy (HTS and/or mannitol). rather than prophylactic doses. platelet transfusion is not of these therapies has been shown to improve recommended routinely. enoxaparin. rFVIIa (90 µg/kg intravenous once) has shown some efficacy Management of intraventricular haemorrhage and and therefore is recommended instead. Platelet transfu- ciency.1136/svn-2016-000047 5 . leading to delayed communicat- MANAGEMENT OF PERIHAEMATOMA OEDEMA ing hydrocephalus. mannitol and HTS are the first-line medical therapies for patients with symptomatic cerebral oedema and elevated ICP. midline shift and brain herniation. brainstem compression or hydro. with majority occurring at or near pression. the clot also causes inflammation and fibrosis of the arachnoid granulations. ation in patients with supratentorial ICH.49 50 Accelerated Resolution of Intraventricular Hemorrhage Patients with asymptomatic PHE require no specific treat- III (CLEAR III) trial showed no outcome benefit. of 3% of HTS for sodium goal of 145–155 mmol/L was Utilisation of minimally invasive techniques for clot associated with less cerebral oedema and ICP crisis evacuation.54 The Minimally-Invasive Surgery plus rtPA for In real-world practice.48 Data from several clinical trials trial evaluating the use of intraventricular tPA adminis- indicate that the absolute increase in PHE during the tration in patients with IVH has completed enrolment. placebo controlled clinical the size of haematoma. EVD placement alone is not sufficient based studies have shown no association between clinical 6 Dastur CK. in most patients with small ICH. benefit from emergent haematoma evacuation.51 Early continuous infusion improvement in functional outcomes. For example.57 Prospective and population- cephalus.1136/svn-2016-000047 .40 Recently. randomised.45 It showed a trend heart failure should receive a bolus of mannitol or towards improved outcomes in the surgical patients com- 23.46 47 Randomised the surgical group. The HTS can be used for patients with dehydration or ongoing MISTIE III trial has added a Stereotactic decreased urine output. Mannitol is an osmotic diuretic. phase III. Preliminary data Of note. There is Subgroup analysis showed reduced mortality in patients no indication for routine use of osmotic agents. transinsular Evacuation (MISTIE) II study revealed significant associ- minimal invasive approaches may yield better results due ation of haematoma removal and oedema reduction in to relative sparing of cortical function. large lobar ICH or temporal lobe haemorrhage may also dymal layer and subependymal brain tissue.55 56 Lobar ICH with cortical involvement is the >3 cm in diameter. ment except maintaining a normal sodium goal. The degree and growth of PHE are strongly related to multicentre.4% of analysis shows a small survival benefit in patients with HTS was associated with rapid reversal of transtentorial superficial lobar haemorrhages without significant herniation and reduced ICP.12 27 Select patients with breakdown products cause inflammation of the epen.Open Access Apart from clotting the cerebral aqueduct leading to treatment and may lead to upward herniation and obstructive hydrocephalus.45 Additional study is warranted to controlled studies are required to evaluate their clinical show the effect on outcomes. cerebellar ICH is consid- ered a neurosurgical emergency and evacuation is SEIZURE PROPHYLAXIS AND TREATMENT recommended per current guidelines given the high Patient with ICH have up to 16% risk of clinical seizures morbidity from rapid development of brainstem com. It SURGICAL INTERVENTION increases water excretion by the kidneys and reduces The International Surgical Trial in Intracerebral cerebral oedema and ICP. It was shown to clear IVH without increasing mass effect. treatment with 23. However.44 The study analysis of the INTERACT2 data showed that mannitol showed a significant improvement in neurological func- seems safe. possible.48 49 50 perihaemorrhagic oedema. Press Release—18 February 2016). CT-guided Endoscopic Surgery arm. In addition. whereas continuous infusion of 3% of pared with the medically managed patients. most important risk factor. a large. with acute ICH.43 In a clinical (>20 mm Hg for > 20 min or new anisocoria) than his- trial performed in China a decade ago. 377 patients torical control (n=64). doi:10.53 A recent aspiration versus conservative treatment. Intraventricular fibrinolysis with rtPA Perihaematomal oedema (PHE) develops within the was an emerging therapy for clearing IVH as soon as first few days after ICH and may cause elevated ICP. within 1 week.4% of HTS. may be promising. such as with large IVH (2016 International Stroke Conference mannitol or HTS. HTS increases plasma osmo- Hemorrhage (ISTICH) and the subsequent STICH II larity and the flow of excess water from cerebral tissue to demonstrated no benefit for early haematoma evacu- the blood via the osmotic gradient. Stroke and Vascular Neurology 2017. benefit. first 24–72 hours was associated with worse functional The preliminary results of the Clot Lysis: Evaluating outcomes at 90 days after ICH. intraventricular blood and its further neurological decline. Minimally Invasive Surgery Plus tPA for ICH showed that the newer trans-sylvian. Unlike supratentorial ICH. Yu W.20 Surgical indications include haematoma size onset.00:e000047.52 A meta-analysis performed in with basal ganglia ICH were randomised to treatment 2011 showed that HTS is slightly more effective than with minimally invasive craniopuncture and needle mannitol for the treatment of elevated ICP. but might not improve outcome in patients tion at 2 weeks and 3 months without mortality benefit.41 42 Subgroup In a small retrospective study. patients with congestive clot breakdown and aspiration. however. the patient’s medical history Intracerebral Hemorrhage Evacuation (MISTIE) phase and the side effect profiles of mannitol and HTS may be II trial evaluated the utilisation of stereotactic clot cath- the major factors for choosing an osmotic agent for an eterisation and intermittent dosing of rtPA to facilitate individual patient. Mechanical VTE prophylaxis should be continued after 2. inferior vena is unclear. temic anticoagulation depending on stability of the haema- graphic seizures on continuous electroencephalographic toma.20 acetaminophen administration.20 It is rea. neurocritical care have contributed to improved survival. Haverbusch M. monitoring. fore essential to prevent VTE. cause of haemorrhage and time since presentation.00:e000047. It is there. the original work is properly cited and the use is non-commercial. and license their derivative works on different terms.0/ ated compression stockings (GCS) can be utilised. Continued research into prevention and effective therapy is pivotal in reducing disease burden and DEEP VEIN THROMBOSIS PROPHYLAXIS AND TREATMENT improving functional recovery.58 59 Patients with DVT or PE should be considered for sys- Between 28% and 31% of patients will have electro.73–76 This raises concerns for ‘self-fulfilling prophecies’. Neurology 2006. therapeutic normother- mia was shown to be associated with increased duration of sedation. A proportion to the degree of brain injury. 1. See: http:// creativecommons. Guidelines published by the Neurocritical Care Open Access This is an Open Access article distributed in accordance with Society in December 2015 recommend the initiation of the Creative Commons Attribution Non Commercial (CC BY-NC 4. Yu W.77 likely due to fewer FEVER CONTROL withdrawal of life support. outcome. Patients with pre-existing DNR orders are mothermia was shown to improve outcome.66–70 The inci- dence of symptomatic pulmonary embolism (PE) is Competing interests None declared. preferably with intermit. The ICH score was developed to predict 30-day mortality rate and func- GLUCOSE MANAGEMENT tional outcomes at 1 year. mechanical VTE prophylaxis. doi:10. mechanical ventilation and Neuro-ICU CONCLUSIONS length of stay without discharge outcome benefit. such as do- to avoid hyperglycaemia and hypoglycaemia. Qureshi AI.20 71 ciated with worse outcomes in several studies. unless explicitly indicated.59 60 Continuous EEG monitoring should be considered for PROGNOSIS patients with ICH with depressed mental status out of ICH is the most debilitating and deadly type of stroke. Recent advances in early diagnosis and ICH except in the setting of clinical trials. Long-term mortality after initiation of pharmacological prophylaxis. ing haematoma volume and location. intracerebral hemorrhage. Sekar P. WY is responsible revising (VTE) in patients with ICH.3°C despite interventions. Broderick JP. ∼0. Several studies have shown that with- risk of morbidity and mortality. Prophylactic phenytoin usage has been asso.0) license. provided of admission. including the ICH score. internally peer reviewed. GCS score on presentation. cava filter placement should be considered.344:1450–60. intraventri- changes in mental status. with the rate of symptom- the manuscript critically for important intellectual content. particularly in patients with The current AHA/ASA guidelines recommend early intraventricular extension. Spontaneous intracerebral hemorrhage.68–70 Up to half of the PE are fatal. Of note. Provenance and peer review Commissioned.61 However.66:1182–6.20 71 If IPC devices are unavailable. age. within the first day of hos- sonable to target glucose level at 100–150 mg/dL for pitalisation are an independent predictor of poor patients with ICH. Tuhrim S. N Engl J Med 2001. not-resuscitate (DNR) orders. glucose 80–110 mg/dL increases hypoglycaemia and the is proven reliable.62 Care should be taken drawal of support and early care limitations.58 The clinical impact of subclinical seizures If systemic anticoagulation is contraindicated. Sustained fever after ICH is and aggressive care after ICH and postponement of any an independent prognostic factor for worse outcome. et al. build upon this work non- tent pneumatic compression (IPC) devices at the time commercially. neither therapeutic hypothermia nor nor.72 73 Most patients die from Hyperglycaemia on admission is associated with worse ICH within the initial hospitalisation due to presumed morbidity and mortality independent of the presence of poor outcome leading to withdrawal of care. et al.20 cular extension and anticoagulant use. Clinical sei- number of factors may affect outcome after ICH. includ- zures should be treated with antiepileptic medications.74 None of diabetes.1136/svn-2016-000047 7 . There is a significant risk of venous thromboembolism Contributors CKD is involved in drafting the work. However. Data sharing statement No additional data are available. remix. haematoma as should electrographic seizures accompanied by expansion. DNR retrospective case–control study of patients with spontan. Open Access seizures and neurological outcome or mortality.5–2%. Flaherty ML. Stroke and Vascular Neurology 2017. treatment. gradu. adapt. atic deep vein thrombosis (DVT) at 1–5%. Dastur CK. status should not limit appropriate medical and surgical eous ICH having two consecutive fevers ≥38.64 65 In a excluded from this recommendation. tight glucose control with target the existing prediction models. 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