From the Guidelines
Patients with intracerebral hemorrhage (ICH) should be managed in a multidisciplinary care setting, such as a stroke unit or intensive care unit, to minimize the risks of common medical complications, including increased intracranial pressure, seizures, venous thromboembolism, fever, hyperglycemia, and hospital-acquired infections. The most frequent complications of ICH include:
- Increased intracranial pressure
- Seizures
- Venous thromboembolism
- Fever
- Hyperglycemia
- Hospital-acquired infections To minimize these complications, the following interventions are recommended:
- Maintain head elevation at 30 degrees and ensure adequate sedation to minimize increased intracranial pressure 1
- Consider osmotic therapy with mannitol (0.25-1 g/kg IV every 4-6 hours) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) for increased intracranial pressure 1
- Use levetiracetam (500-1000 mg IV twice daily) for seizure prevention in patients with lobar hemorrhages or those who have experienced clinical seizures 1
- Initiate mechanical prophylaxis immediately and consider pharmacological prophylaxis with low molecular weight heparin (enoxaparin 40 mg subcutaneously daily) or unfractionated heparin (5000 units subcutaneously every 8-12 hours) after 24-48 hours when bleeding has stabilized to prevent venous thromboembolism 1
- Treat fever aggressively with acetaminophen (650 mg every 4-6 hours) and cooling measures to maintain normothermia 1
- Maintain blood glucose between 140-180 mg/dL using insulin protocols 1
- Implement ventilator-associated pneumonia bundles, early removal of urinary catheters, and strict hand hygiene to prevent infections 1
- Early mobilization and rehabilitation are crucial to prevent complications of immobility 1 These interventions are essential as each complication can worsen outcomes by exacerbating secondary brain injury, increasing mortality, and prolonging hospital stays in ICH patients.
From the Research
Common Medical Complications in ICH Patients
- Edema: Management of edema is a key aspect of ICH treatment, as it can lead to increased intracranial pressure and further brain damage 2, 3.
- Coagulopathy: Correction of coagulopathy is crucial in ICH patients, as it can help prevent further bleeding and hematoma expansion 2, 3, 4.
- Raised intracranial pressure: Prevention and management of raised intracranial pressure are critical in ICH patients, as it can lead to brain herniation and death 5, 3.
- Thromboembolic complications: Patients with ICH are at risk of thromboembolic complications, particularly if they are taking anticoagulant medications 3.
- Cerebral ischemia: ICH patients are also at risk of cerebral ischemia, which can further exacerbate brain damage 3.
Minimizing Risks
- Early aggressive treatment: Early initiation of supportive medical therapies, including blood pressure management, in a neurological intensive care unit can reduce mortality 2, 3.
- Correction of coagulopathies: Correction of known coagulopathies and reversal of oral anticoagulation can help prevent further bleeding and hematoma expansion 3, 4.
- Blood pressure management: Meticulous control of blood pressure is crucial in ICH patients, as it can help prevent further bleeding and hematoma expansion 2, 3, 4.
- Surgical interventions: Surgical interventions, such as minimally invasive surgery, may be necessary in some cases to reduce intracranial pressure and prevent further brain damage 3, 6.
- Admission to critical care units: Patients with ICH should be admitted to capable critical care units, with expertise in neurocritical care if available, to receive optimal care and management 4.