What is the management for an intraparenchymal intracerebral hemorrhage?

Management of Intraparenchymal Intracerebral Hemorrhage

Immediately transfer the patient to a neuroscience intensive care unit or dedicated stroke unit, reduce systolic blood pressure to <140 mmHg within 6 hours, reverse any coagulopathy, and consider surgical evacuation only for cerebellar hemorrhages with neurological deterioration or for select patients with lobar hemorrhages and GCS 9-12. 1, 2

Initial Stabilization and Assessment

• Secure the airway via endotracheal intubation if GCS ≤8, maintaining PaO₂ between 60-100 mmHg and PaCO₂ between 35-40 mmHg to prevent cerebral vasoconstriction 2
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during initial resuscitation to prevent secondary brain injury 2
• Obtain non-contrast CT scan immediately as the gold standard for diagnosis, and perform CT angiography to identify patients at risk for hematoma expansion 2
• Admit directly to neuroscience ICU or dedicated stroke unit with physician and nursing neuroscience expertise, avoiding prolonged ED stays which worsen outcomes 2, 3

Blood Pressure Management

• Target systolic blood pressure <140 mmHg for patients presenting with SBP 150-220 mmHg, beginning blood pressure control immediately after ICH onset 1, 2
• This intensive blood pressure reduction should occur within the first 6 hours of symptom onset 1
• Avoid hypotension (SBP <100 mmHg or MAP <80 mmHg) as it worsens secondary brain injury 2

Reversal of Coagulopathy

• For patients on vitamin K antagonists (warfarin): immediately withhold the medication, administer prothrombin complex concentrates (PCC) or fresh frozen plasma (FFP) plus intravenous vitamin K to correct INR 2
• For severe thrombocytopenia or coagulation factor deficiency: administer appropriate factor replacement or platelets 2
• Avoid routine hemostatic therapy for ICH not associated with antithrombotic drug use 1

Intracranial Pressure and Hydrocephalus Management

• Place ventricular drainage catheter for hydrocephalus, especially in patients with decreased level of consciousness 1, 4, 2
• Consider ICP monitoring for patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant intraventricular hemorrhage or hydrocephalus 1, 4, 2
• Maintain cerebral perfusion pressure (CPP) of 50-70 mmHg depending on autoregulation status 1, 4, 2
• Do NOT administer corticosteroids for treatment of elevated ICP in ICH 1, 4
• Ventricular catheters are preferred over parenchymal monitors when safe and feasible as they allow both ICP monitoring and CSF drainage 4

Surgical Decision-Making

Cerebellar Hemorrhage

• Patients with cerebellar hemorrhage >3 cm who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible 5, 1
• This is the clearest indication for surgery, as clinical equipoise does not exist for randomized trials given the dramatic outcome differences 5
• Ventricular catheter alone is insufficient and not recommended, especially in patients with compressed cisterns 5

Supratentorial Hemorrhage

• For most patients with supratentorial ICH, routine surgical evacuation is not recommended 5, 2
• Consider surgery for patients with lobar hemorrhages and GCS 9-12, as this subgroup showed a trend toward better outcomes 5, 1
• Surgery may be considered for superficial lobar hemorrhages (within 1 cm of cortical surface), though benefits are not definitively established 5, 1
• Patients with deep hemorrhages (>1 cm from cortical surface) or GCS ≤8 tend to do worse with surgical removal compared to medical management 5
• Do NOT routinely evacuate capsuloganglionic (deep) hemorrhages, as the STICH trial showed no benefit 2

Timing Considerations

• Early surgery within 4 hours carries increased risk of rebleeding 5
• Studies examining surgery within 12-96 hours have shown mixed results, with no clear benefit except for specific subgroups noted above 5

Prevention of Complications

• Avoid graduated compression stockings 1
• Use intermittent pneumatic compression in immobile patients 1
• Initiate pharmacologic thromboembolism prophylaxis after documenting hematoma stability on CT, generally between 24-48 hours after ICH onset 1
• Treat clinical seizures with antiseizure drugs, and treat electrographic seizures detected on EEG 2
• Maintain normothermia and aggressively treat fever to normal levels, as fever duration correlates with worse outcomes 2
• Monitor glucose continuously, avoiding both hyperglycemia and hypoglycemia, targeting glucose <300 mg/dL (16.63 mmol/L) at minimum 2

Rehabilitation

• All patients with ICH should have access to multidisciplinary rehabilitation 1
• Rehabilitation should be initiated as early as possible and continue in the community as part of a well-coordinated discharge program 1

Common Pitfalls

• Do not delay blood pressure reduction beyond 6 hours, as early intervention is critical 1, 2
• Do not place ICP monitors without first evaluating coagulation status and considering platelet transfusion for patients on prior antiplatelet therapy 4
• Risk of infection with ventricular catheters is approximately 4%, and risk of intracranial hemorrhage with catheter placement is approximately 3% (higher at 15.3% in patients with coagulopathies) 4
• Hematoma expansion occurs in 28-38% of patients scanned within 3 hours of onset, so consider repeat imaging if clinical deterioration occurs 2
• More than 20% of patients experience early neurological deterioration with a decline in GCS of two or more points in the first hours 1