From the Guidelines
Neurological deficits after spontaneous intracranial hemorrhage (ICH) can be severe and varied, but with proper management, including controlling blood pressure and preventing secondary injury, patients can experience significant recovery, with the most recent guidelines recommending a systolic blood pressure target of <140 mmHg 1.
Initial Management
Initial management of ICH focuses on stabilizing the patient, controlling blood pressure, and preventing secondary injury. Controlling blood pressure is crucial, as it can help prevent further bleeding and reduce the risk of hematoma expansion. The most recent guidelines recommend maintaining a systolic blood pressure below 140 mmHg with agents like labetalol or nicardipine 1.
Common Deficits
Common neurological deficits after ICH include:
- Hemiparesis
- Speech disorders
- Cognitive impairment
- Sensory disturbances These deficits can vary widely depending on the location and extent of bleeding.
Rehabilitation
Rehabilitation should begin as early as safely possible, often within 24-48 hours of stabilization. A multidisciplinary approach is necessary, with physical therapy, occupational therapy, and speech therapy tailored to specific deficits. Regular neurological assessments using standardized scales like the NIH Stroke Scale help track progress and adjust treatment plans accordingly.
Medications
Medications may include anticonvulsants like levetiracetam (500-1000 mg twice daily) if seizures occur, and careful pain management with acetaminophen or low-dose opioids while avoiding NSAIDs. Depression is common after ICH and may require treatment with SSRIs like sertraline (starting at 25-50 mg daily) 1.
Recovery
Recovery typically follows a logarithmic curve, with most improvement occurring in the first 3-6 months, though some patients continue to show progress for years. Neuroplasticity underlies recovery, as healthy brain regions gradually assume functions of damaged areas through intensive, repetitive, and task-specific rehabilitation exercises. The most recent guidelines emphasize the importance of early and intensive rehabilitation to improve outcomes 1.
From the Research
Neurological Deficits after Spontaneous Intracranial Hemorrhage (ICH)
- The majority of patients with spontaneous intracranial hemorrhage (ICH) experience significant neurological deterioration, which can be due to the mass effect of the hematoma or other factors such as increased intracranial pressure 2, 3.
- Common neurological deficits after ICH include hemiplegia, decreased level of consciousness, and cognitive impairment 3, 4.
- The severity of neurological deficits can vary depending on the location and size of the hematoma, as well as the patient's underlying medical conditions 3, 4.
- Patients with large motor-strip AVMs or those with cerebellar hemorrhages larger than 3 cm are at higher risk of developing severe neurological deficits 2, 3.
Factors Influencing Neurological Deficits
- Hypertension is a major risk factor for ICH and can contribute to the development of neurological deficits 3, 4.
- The use of anticoagulant medications, such as warfarin, can increase the risk of ICH and subsequent neurological deficits 4.
- The timing and nature of neurosurgical interventions, such as hematoma evacuation, can also impact the development of neurological deficits 3, 4.
Management of Neurological Deficits
- Aggressive management of ICH in a specialist neurointensive care unit, including monitoring and managing cardiorespiratory variables and intracranial pressure, can improve outcomes 4.
- The use of intracranial pressure monitors, such as external ventricular drains and intraparenchymal monitors, can provide valuable information to guide treatment, but its impact on neurologic outcome is unclear 5.
- Early surgical intervention, including hematoma evacuation and AVM excision, can be beneficial in selected patients with moderate to large lobar or basal ganglia hemorrhages 2, 3.