What is the management of intraparenchymal hemorrhage?

Management of Intraparenchymal Hemorrhage

Intraparenchymal hemorrhage requires immediate medical attention with rapid diagnosis and aggressive early management to prevent neurological deterioration and improve outcomes. 1

Initial Assessment and Diagnosis

• Rapid neuroimaging: CT scan is the gold standard for identifying acute hemorrhage and should be completed within 45 minutes of ED arrival 1

  • MRI with gradient echo (GRE) and T2* susceptibility-weighted imaging is equally sensitive for acute blood detection and more sensitive for prior hemorrhage 1, 2
  • CT angiography should be considered to evaluate for underlying vascular abnormalities 1

• Clinical assessment:

  • Document Glasgow Coma Scale (GCS) score
  • Monitor for early neurologic deterioration (occurs in ~23% of patients with initial GCS ≥13) 3
  • Risk factors for deterioration: antiplatelet use, arrival <3 hours from symptom onset, temperature ≥37.5°C, intraventricular hemorrhage, and midline shift >2mm 3

Emergency Management

1. Airway and ventilation support:

   • Secure airway if GCS ≤8 or deteriorating respiratory status
   • Transport to nearest facility prepared for acute stroke care 1

2. Blood pressure management:

   • Target systolic BP <140 mmHg within 6 hours of ICH onset 1, 4
   • Use beta-blockers or calcium channel blockers for controlled reduction 5
   • Maintain cerebral perfusion pressure (CPP) between 50-70 mmHg in patients with ICP monitoring 1

3. Coagulopathy reversal:

   • Correct coagulopathy immediately with appropriate reversal agents 4
   • For warfarin-related ICH, administer prothrombin complex concentrate (preferred over fresh frozen plasma) plus vitamin K 4
   • Platelet transfusion for patients on antiplatelet therapy is not beneficial and may be harmful 5

4. Seizure management:

   • Treat clinical seizures with antiseizure medications 4
   • Consider EEG monitoring in patients with altered mental status 4

Intracranial Pressure Management

• ICP monitoring indications:

  • GCS score ≤8
  • Clinical evidence of transtentorial herniation
  • Significant intraventricular hemorrhage or hydrocephalus 1

• Ventricular drainage:

  • Ventricular catheter placement for CSF drainage is recommended for hydrocephalus, especially in patients with decreased level of consciousness 1
  • Consider risks: infection (2.9-4%) and intracranial hemorrhage (2.1-3%), higher in patients with coagulopathies 1

• ICP management targets:

  • Maintain CPP 50-70 mmHg depending on cerebral autoregulation status 1
  • Avoid routine elevation of CPP >70 mmHg due to risk of respiratory distress syndrome 4
  • Do not use corticosteroids for ICP management in ICH patients 1

Surgical Management

• Hematoma evacuation:

  • No compelling evidence that routine surgical evacuation of supratentorial hematomas is beneficial 1
  • Consider surgery for:
    • Cerebellar hemorrhages with neurological deterioration or brainstem compression 1
    • Large hemispheric lesions with impending herniation 1
    • Hydrocephalus requiring CSF diversion 1

• Minimally invasive approaches:

  • Stereotactically guided drainage with intraventricular thrombolysis has shown promise for ICH with intraventricular extension 5

Ongoing Care

• Admission location:

  • Admit to neuroscience ICU or dedicated stroke unit with neuroscience expertise 4

• Venous thromboembolism prophylaxis:

  • Use intermittent pneumatic compression beginning on admission day 4
  • Avoid graduated compression stockings 4

• Monitoring and follow-up:

  • Repeat neuroimaging to assess for hematoma expansion
  • Monitor for seizures, especially in patients with lobar hemorrhages
  • Screen for dysphagia before initiating oral intake 4
  • Monitor glucose and avoid both hyperglycemia and hypoglycemia 4

Prognosis

• ICH has poor prognosis with 30-day mortality of 35-52% 4
• Only about 20% of patients achieve functional independence after 6 months 4
• One-year mortality varies by location:
  • Deep hemorrhages: 51%
  • Lobar hemorrhages: 57%
  • Cerebellar hemorrhages: 42%
  • Brainstem hemorrhages: 65% 4

Rehabilitation

• All patients should receive multidisciplinary rehabilitation 4
• Early mobilization and rehabilitation should begin as soon as the patient is medically stable

Pitfalls and Caveats

• Early neurological deterioration is common (>20% experience GCS decrease of ≥2 points between EMS assessment and ED evaluation) 1
• Hydrocephalus is an important cause of ICH-related morbidity and mortality and should be promptly identified and treated 1
• Avoid delaying surgery when indicated as this increases mortality risk 4
• Risk of rebleeding from untreated vascular anomalies necessitates thorough evaluation for underlying causes 1