From the Guidelines
Intracranial hemorrhage (ICH) in young patients is a medical emergency due to the high risk of early neurological deterioration and poor long-term outcomes, necessitating rapid diagnosis and aggressive management. When a young patient presents with ICH, immediate evaluation is crucial because over 20% of patients will experience a decrease in the Glasgow Coma Scale (GCS) of two or more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the emergency department 1. The risk for early neurologic deterioration and the high rate of poor long-term outcomes underscores the need for aggressive early management.
Key Considerations
- Rapid diagnosis and attentive management of patients with ICH is crucial because early deterioration is common in the first few hours after ICH onset 1.
- More than 20% of patients will experience a decrease in the GCS of 2 or more points between the prehospital EMS assessment and the initial evaluation in the ED, with a mortality rate of over 75% among those with prehospital neurologic decline 1.
- The urgency stems from the confined space within the skull; as hemorrhages expand, they compress vital brain structures, disrupt cerebrospinal fluid circulation, and can cause herniation syndromes.
- Young patients may initially compensate well for increasing intracranial pressure, masking symptoms until decompensation occurs suddenly and catastrophically.
Management Approach
- Emergent management may include neurosurgical interventions for hematoma evacuation, external ventricular drainage or invasive monitoring and treatment of ICP, blood pressure management, intubation, and reversal of coagulopathy 1.
- Immediate neurosurgical evaluation and urgent imaging such as CT or MRI are necessary to assess the size, location, and characteristics of the hemorrhage.
- Treatment typically involves surgical intervention to relieve pressure, followed by appropriate management based on the patient's condition.
- The importance of having a plan for rapid transfer to a tertiary care center if necessary, and the need for critical care facilities including adequately trained nurses and physicians, cannot be overstated 1.
From the Research
Importance of Timely Intervention in Young Patients with Ischemic Stroke
- Ischemic stroke in young patients is a serious condition that requires immediate attention, as timely intervention can minimize long-term disability 2.
- The incidence of ischemic stroke in young adults has been increasing, and this population has a wider range of risk factors, including age-specific factors and behavioral risk factors 3.
Consequences of Delayed Treatment
- Delayed treatment can lead to increased morbidity and mortality, as well as long-term disability 4, 5.
- Young stroke survivors often experience adverse outcomes, including epilepsy, pain, cognitive problems, and depression, emphasizing the need for prompt intervention 3.
Factors Associated with Acute Stroke Intervention
- Arrival by ambulance is significantly associated with acute stroke intervention in young adults, highlighting the importance of prehospital care 2.
- Systematic identification of risk factors and causes, as well as motivation for long-term prevention and lifestyle changes, are crucial to improving prognosis 3.
Management and Treatment
- Management of acute ischemic stroke in young patients involves a range of treatments, including thrombolysis and endovascular therapy 4, 5.
- Optimal treatments for specific conditions, such as cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome, are still being researched 6.