Management of Right Basal Ganglia Hemorrhage in a 62-Year-Old Male with Hypertensive Crisis
For this patient with acute right basal ganglia hemorrhage (12.8cc) presenting within hours of onset with severe hypertension (BP 180/100 on admission, currently 140-120/90-80), the priority is aggressive blood pressure control targeting systolic BP <140 mmHg, intensive neurological monitoring in a neuroscience ICU, and avoidance of surgical intervention given the deep location and moderate hematoma size.
Immediate Blood Pressure Management
Target systolic BP <140 mmHg achieved within 1 hour and maintained for at least 7 days 1. The patient's current BP of 140-120/90-80 is at the upper limit of the target range and requires optimization.
Labetalol is the first-line intravenous agent for acute BP control in ICH, as it preserves cerebral blood flow and does not increase intracranial pressure 1, 2. Dosing: 5-20 mg IV bolus every 15 minutes or continuous infusion at 2 mg/min 2.
Nicardipine is an acceptable alternative, starting at 5 mg/hour IV infusion and titrating to effect 2.
Continuous intra-arterial BP monitoring should be strongly considered given the need for IV vasoactive medications and the risk of excessive BP drops 1, 2.
Avoid drops in systolic BP >70 mmHg acutely, as this is associated with acute renal injury and early neurological deterioration 3, 2.
The INTERACT2 trial demonstrated that intensive BP lowering (SBP <140 mmHg within 1 hour) in patients presenting with SBP 150-220 mmHg within 6 hours of ICH onset resulted in better functional recovery and quality of life, though the primary endpoint of death or major disability showed only a favorable trend 1.
Critical Monitoring Requirements
Admission to a neuroscience intensive care unit is associated with reduced mortality and is essential for this patient 1.
Neurological assessments using NIHSS or GCS should be performed at baseline and repeated at least hourly for the first 24 hours 1.
BP monitoring every 15 minutes until stabilized, then every 30-60 minutes for at least 24-48 hours 1, 3, 2.
Continuous cardiopulmonary monitoring including automated BP cuff, ECG telemetry, and pulse oximetry 1.
Assess for clinical signs of increased intracranial pressure including worsening level of consciousness, pupillary changes, and Cushing's triad 1.
Hematoma Expansion Prevention
Hematoma expansion occurs in 28-38% of patients scanned within 3 hours of onset and is a major predictor of poor outcome 1.
Repeat CT scan should be performed if there is any neurological deterioration to assess for hematoma expansion, increased edema, or hydrocephalus 1.
The patient is not on anticoagulation or antiplatelet agents, which is favorable, as these would require immediate reversal 1.
Surgical Considerations
Surgery is NOT recommended for this patient given the deep basal ganglia location and moderate hematoma size (12.8cc).
Craniotomy for deep hemorrhages (basal ganglia, thalamus) has not demonstrated benefit and may be harmful 1. The STICH trial showed no significant benefit for early surgery versus initial conservative treatment for supratentorial ICH 1.
Surgical intervention is reserved for: cerebellar hemorrhages with brainstem compression or hydrocephalus, lobar hemorrhages with progressive deterioration and mass effect, or ventricular drainage for hydrocephalus 1, 4.
Minimally invasive techniques are under investigation but remain experimental for deep hemorrhages 1.
Management of Concurrent Medical Issues
Diabetes Management
The patient has newly recognized diabetes (HbA1c 7.0%, CBG ranging 128-317 mg/dL). Starting insulin glargine 10 units AM and 5 units PM is appropriate, with target glucose 140-180 mg/dL to avoid both hyperglycemia and hypoglycemia, which can worsen outcomes 1.
Hypertension Management
Continue Losartan 50mg daily as part of long-term BP control 3. The patient's medication non-compliance for 1 week prior to the hemorrhage was likely a major contributing factor 5, 6.
After 24-48 hours, transition from IV to oral antihypertensive agents once acute control is achieved and the patient is stable 3, 2.
Long-term target BP <140/90 mmHg to prevent recurrent ICH, which occurs in up to 2-5% of patients within 2 years, predominantly in those with poorly controlled hypertension 3, 7.
Statin Therapy
Atorvastatin 40mg daily is reasonable for long-term vascular risk reduction, though it does not affect acute ICH outcomes 1.
Medications to AVOID or DISCONTINUE
Stop Nimodipine immediately - this calcium channel blocker is indicated for subarachnoid hemorrhage, NOT intracerebral hemorrhage, and may cause excessive BP lowering 1.
Mannitol should be used judiciously and only if there is evidence of elevated ICP or impending herniation, as routine use is not supported 1.
Avoid nitroprusside as it may increase ICP and have negative effects on hemostasis 2.
Seizure Management
Prophylactic antiepileptic drugs are NOT routinely recommended unless clinical or electrographic seizures occur 1. Clinical seizures occur in up to 16% of ICH patients, mostly at onset 1.
Prognosis and Counseling
The patient's baseline GCS of 15 and moderate hematoma size (12.8cc) are favorable prognostic factors 1. However, the complete left-sided motor and sensory deficit indicates significant injury. Functional recovery will depend on preventing hematoma expansion, controlling secondary brain injury from perihematomal edema, and intensive rehabilitation 1.
Perihematomal edema develops over hours to weeks and represents secondary brain injury from blood degradation products, thrombin, and neuroinflammation 1. This is a target for neuroprotective strategies but currently lacks proven therapies.