What is the management of Intracranial Hemorrhage (ICH) in the Intensive Care Unit (ICU)?

From the Guidelines

Management of intracranial hemorrhage (ICH) in the ICU requires immediate stabilization, neurological monitoring, and targeted interventions to prevent secondary brain injury, with initial monitoring and management taking place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1.

Key Components of Management

• Securing the airway with rapid sequence intubation using propofol (1-2 mg/kg) or etomidate (0.3 mg/kg) and maintaining normocapnia (PaCO2 35-40 mmHg)
• Blood pressure control with systolic targets of <140-160 mmHg for most ICH patients, achievable with nicardipine (5-15 mg/hr), labetalol (10-20 mg boluses or 0.5-2 mg/min infusion), or clevidipine (1-2 mg/hr initially, titrated up) 1
• Elevated intracranial pressure (ICP) management with head elevation to 30°, osmotic therapy using mannitol (0.25-1 g/kg IV q4-6h) or hypertonic saline (3% NaCl at 0.5-1 mL/kg/hr), and CSF drainage if necessary
• Seizure prophylaxis with levetiracetam (500-1000 mg IV q12h) is recommended for patients with lobar hemorrhages or clinical seizures 1
• Temperature control (target <37.5°C), glucose management (140-180 mg/dL), and DVT prophylaxis with intermittent pneumatic compression devices are essential 1
• Reversal of coagulopathy is critical - for warfarin-associated ICH, administer 4-factor PCC (25-50 IU/kg) with vitamin K (10 mg IV); for DOACs, use specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors

Neurosurgical Consultation

Neurosurgical consultation is warranted for large hematomas with mass effect, cerebellar hemorrhages >3 cm, or deteriorating neurological status 1.

Evidence-Based Recommendations

The American Heart Association/American Stroke Association guidelines recommend a comprehensive approach to managing ICH, including initial monitoring and management in an intensive care unit or dedicated stroke unit, blood pressure control, and reversal of coagulopathy 1. The European Stroke Organisation guidelines also emphasize the importance of managing ICH in a specialized unit and controlling blood pressure 1.

Prioritization of Outcomes

The management of ICH in the ICU prioritizes morbidity, mortality, and quality of life as the primary outcomes, with a focus on preventing secondary brain injury and improving patient outcomes 1.

From the Research

Management of Intracranial Hemorrhage (ICH) in the Intensive Care Unit (ICU)

The management of ICH in the ICU involves several key strategies, including:

• Early airway protection, control of malignant hypertension, urgent reversal of coagulopathy, and surgical intervention to increase the chance of survival for patients with severe ICH 2
• Intensive lowering of systolic blood pressure to <140 mmHg, which is proven safe by recent randomized trials 2
• Correction of known coagulopathies and reversal of oral anticoagulation, but no routine transfusion of platelets in patients taking aspirin or clopidogrel 2, 3
• Consideration of early surgical intervention, including ventriculostomy for patients with severe intraventricular hemorrhage, hydrocephalus, or elevated intracranial pressure (ICP) 2, 4
• Prevention of secondary brain injury through timely and aggressive management in the acute phase, including prevention of hematoma expansion and management of blood pressure and coagulopathy 4, 5

Medical Management

Medical management of ICH in the ICU includes:

• Control of blood pressure, with a goal of keeping systolic blood pressure <140 mmHg 2
• Reversal of coagulopathy, including correction of known coagulopathies and reversal of oral anticoagulation 2, 3
• Use of mannitol or hypertonic saline (HTS) for emergent treatment of worsening cerebral edema, elevated ICP, or pending herniation 2
• Maintenance of serum sodium level at 140-150 mEq/L for 7-10 days to minimize edema expansion and mass effect in patients with large ICH or symptomatic perihaematoma edema 2

Surgical Management

Surgical management of ICH in the ICU includes:

• Ventriculostomy for patients with severe intraventricular hemorrhage, hydrocephalus, or elevated ICP 2, 4
• Emergent hematoma evacuation for patients with large cerebellar or temporal ICH 2, 4
• Consideration of early surgical intervention for patients with severe ICH, including those with large hematomas or significant mass effect 6, 4

Preventive Measures

Preventive measures for ICH in the ICU include:

• Use of intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for prophylaxis of venous thromboembolism 2
• No benefit for seizure prophylaxis or aggressive management of fever or hyperglycemia 2