From the Guidelines
Neurological deficits after spontaneous intracranial hemorrhage (ICH) can be severe and varied, including motor weakness, sensory disturbances, speech problems, cognitive impairment, and coordination difficulties, with management prioritizing stabilization, prevention of secondary brain injury, and early rehabilitation to maximize functional outcomes. The location and extent of bleeding play a crucial role in determining the severity of neurological deficits [ 1 ]. Initial management focuses on stabilizing the patient and preventing secondary brain injury through blood pressure control, typically maintaining systolic BP <140 mmHg, using medications like labetalol, nicardipine, or clevidipine [ 1 ]. Neurosurgical intervention may be necessary for large hemorrhages causing significant mass effect or hydrocephalus.
Rehabilitation should begin as early as possible, often within 24-48 hours if the patient is stable, and includes physical therapy, occupational therapy, and speech therapy tailored to specific deficits. Medications may include anticonvulsants if seizures occur, pain management, and prevention of complications like deep vein thrombosis. Recovery typically follows a logarithmic pattern with most improvement occurring in the first 3-6 months, though some patients continue to show improvement for up to a year or longer [ 1 ]. Neuroplasticity plays a crucial role in recovery as the brain forms new neural connections to compensate for damaged areas, which is why early, intensive rehabilitation is essential for maximizing functional outcomes.
Key considerations in managing ICH include:
- Early detection and management of hemorrhagic expansion (HE), which is an independent predictor of mortality and poor functional outcome [ 1 ]
- The use of imaging, such as MRI or CT scans, to detect HE and monitor ICH volume, with repeat imaging at 6 and 24 hours after onset to exclude HE and document final ICH volume [ 1 ]
- The potential benefits and risks of blood pressure control, with evidence suggesting that maintaining systolic BP <140 mmHg may be beneficial in preventing secondary brain injury [ 1 ].
Overall, the management of neurological deficits after spontaneous ICH requires a multidisciplinary approach, prioritizing stabilization, prevention of secondary brain injury, and early rehabilitation to maximize functional outcomes [ 1 ].
From the Research
Neurological Deficits after Spontaneous Intracranial Hemorrhage (ICH)
The neurological deficits after spontaneous intracranial hemorrhage (ICH) can be severe and varied. Some of the key points to consider include:
- The majority of patients with ICH experience significant neurological deterioration due to mass effect from the hematoma 2
- Prompt hematoma evacuation with simultaneous AVM excision, as well as perioperative intracranial pressure control, can yield a good-to-excellent outcome in some patients 2
- Current guidelines endorse early aggressive optimization of physiologic derangements, including blood pressure control, reversal of coagulopathy, and intracranial pressure monitoring 3
- Surgical hematoma evacuation may be a reasonable option for patients with early worsening due to mass effect from large cerebellar or lobar hemorrhages 3
- Management of ICH is largely supportive, with treatment strategies aimed at limiting hematoma enlargement, seizures, and cerebral edema 4
Key Considerations in Management
Some key considerations in the management of ICH include:
- Urgent stabilization of cardiorespiratory variables and treatment of intracranial complications 5
- Acute arterial blood pressure reduction may be safe and associated with slowed hematoma growth and reduced risk of early neurological deterioration 5
- Management of patients with ICH in a specialist neurointensive care unit can be associated with improved outcomes 5
- Attention must be given to fluid and glycemic management, minimizing the risk of ventilator-acquired pneumonia, fever control, provision of enteral nutrition, and thromboembolic prophylaxis 5