What is the management approach for a patient with intraparenchymal hemorrhage (IPH) without Ischemic Heart Disease (IHD)?

Management of Intraparenchymal Hemorrhage (IPH)

In patients with intraparenchymal hemorrhage (IPH), acute blood pressure lowering to a target systolic BP of 140 mmHg is strongly recommended to reduce the risk of hematoma expansion and improve outcomes, regardless of the presence of ischemic heart disease. 1

Initial Assessment and Management

Blood Pressure Control

• Immediately lower systolic blood pressure to a target of 140 mmHg within 6 hours of symptom onset 1
  • For patients with severe hypertension, IV labetalol (10-20 mg bolus, repeated every 10-20 minutes up to 300 mg) is recommended as first-line treatment 2
  • Avoid sudden drops in blood pressure that may compromise cerebral perfusion 2
  • More intensive BP control (systolic BP <120 mmHg) may be beneficial in select patients to reduce risk of recurrent ICH, but should be avoided in patients >75 years or with significant disability (mRS 4-5) due to increased mortality risk 3

Reversal of Anticoagulation

• For patients on anticoagulants, immediately discontinue and reverse anticoagulation 1
  • For VKA-associated IPH with INR ≥2.0: Administer 4-factor prothrombin complex concentrate (PCC) over fresh-frozen plasma, along with IV vitamin K 1
  • For dabigatran: Use idarucizumab 1
  • For factor Xa inhibitors: Use andexanet alpha or 4F-PCC if andexanet alpha is unavailable 1
  • For heparin-related ICH: Administer protamine sulfate 1

Diagnostic Imaging

• Perform non-contrast head CT immediately to confirm diagnosis 1
• Obtain CT angiography (CTA) in patients with:
  • Lobar ICH and age <70 years
  • Deep/posterior fossa ICH and age <45 years
  • Deep/posterior fossa ICH in patients 45-70 years without history of hypertension 1
• Consider catheter angiography for patients with:
  • Spontaneous intraventricular hemorrhage (IVH) without parenchymal component
  • Non-invasive angiography suggestive of vascular anomaly 1

Management of Elevated Intracranial Pressure (ICP)

Ventricular Drainage

• External ventricular drainage (EVD) is recommended for patients with:
  • IVH with hydrocephalus contributing to decreased consciousness 1
  • Significant hydrocephalus requiring CSF diversion 2

ICP Monitoring

• Consider ICP monitoring in patients with:
  • GCS score ≤8
  • Clinical evidence of transtentorial herniation
  • Significant IVH or hydrocephalus 1
• Maintain cerebral perfusion pressure (CPP) between 50-70 mmHg 1, 2

Management of Elevated ICP

• Implement a graded approach:
  1. Elevate head of bed to 30° 2
  2. Provide adequate analgesia and sedation 1
  3. For refractory elevated ICP, consider:
     • Osmotic diuretics (mannitol or hypertonic saline) 1
     • CSF drainage via ventricular catheter 1
     • Neuromuscular blockade 1
     • Hyperventilation (short-term use only) 1
• Avoid corticosteroids for treatment of elevated ICP in IPH 1, 2

Surgical Management

Supratentorial IPH

• Consider minimally invasive surgical evacuation for patients with:
  • Deteriorating neurological status
  • Large hematoma volume
  • Mass effect with midline shift 4, 5

Infratentorial (Cerebellar) IPH

• Surgical evacuation is recommended for patients with:
  • Cerebellar hemorrhage >3 cm in diameter
  • Brainstem compression
  • Hydrocephalus from ventricular obstruction 1, 5
• Consider external ventricular drainage alone in patients with small cerebellar hemorrhages with hydrocephalus 1

Supportive Care

Temperature Management

• Treat fever aggressively to maintain normothermia (temperature <37.5°C) 1
• Avoid therapeutic hypothermia outside clinical trials 1

Glucose Management

• Maintain serum glucose between 140-180 mg/dL 1
• Avoid both hyperglycemia and hypoglycemia 1

Seizure Management

• Administer appropriate antiepileptic therapy for clinical seizures 1
• Routine prophylactic antiepileptic therapy is not recommended 1

Prevention of Complications

• Early mobilization and rehabilitation for clinically stable patients 1
• DVT prophylaxis with intermittent pneumatic compression devices 1
• Consider early enteral nutrition 4

Monitoring and Follow-up

• Frequent neurological assessments using standardized scales (GCS, NIHSS) 2
• Repeat head CT within 24 hours to assess for hematoma expansion 4
• Monitor for neurological deterioration, which may indicate:
  • Hematoma expansion
  • Increasing edema
  • Hydrocephalus
  • Seizures 4, 5

Pitfalls and Caveats

• Avoid hypotension when treating elevated blood pressure, as this may compromise cerebral perfusion 2
• Avoid hypotonic fluids which can worsen cerebral edema; use isotonic solutions 2
• Avoid routine use of corticosteroids for treatment of elevated ICP 1, 2
• Avoid delaying anticoagulation reversal in patients on anticoagulant therapy 1
• Avoid overlooking underlying vascular abnormalities in young patients or those without hypertension history 1
• Avoid excessive sedation that prevents neurological assessment 2

The management of IPH requires prompt intervention focusing on blood pressure control, reversal of coagulopathy, management of elevated ICP, and consideration of surgical intervention in select cases to optimize patient outcomes.