Template:ICH Treatment: Difference between revisions
 
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===Elevating head of bed===
===Elevating head of bed===
*30 degree elevation will help decrease ICP<ref>http://stroke.ahajournals.org/content/38/6/2001.full</ref>
*30 degree elevation will help decrease ICP by increasing venous outflow<ref>http://stroke.ahajournals.org/content/38/6/2001.full</ref>


===[[Seizure]] Prophylaxis===
===[[Seizure]] Prophylaxis and Treatment===
*For example: [[Keppra]] 1000mg IV load
*Prophylactic antiepileptics '''not''' recommended<ref>AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015 </ref>
 
*Continuous EEG monitoring probably indicated in ICH patients with depressed mental status that is out of proportion fo degree of brain injury<ref>AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015 </ref>
===[[Seizure]] Prophylaxis===
*[[Antiepileptics]] indicated for clinical seizures or seizures on EEG in patients with altered mental status<ref>AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015 </ref>
*For example: [[Keppra]] 1,000mg IV load


===Blood Pressure===
===Blood Pressure===
*Few studies on optimal management however many [[Intracranial hemorrhage (main)|guidelines recommending moderate reduction]], often a goal systolic of 140-160's
*Rapid SBP lowering <140 has been advocated with early research showing improved functional outcome<ref>Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013; 368:2355-2365.</ref>, but more recent work has found no difference between SBP <140 and <180<ref>Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016; 1-11. [Epub ahead of print].</ref>
*Rapid SBP lowering <140 has been advocated with early research showing improved functional outcome<ref>Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013; 368:2355-2365.</ref>, but more recent work has found no difference between SBP <140 and <180<ref>Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016; 1-11. [Epub ahead of print].</ref>
*SBP >200 or MAP >150
*SBP >200 or MAP >150
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**Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)
**Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)


Dosing nicardipine in ICH: Start nicardipine at 5mg/hr and increase q5min by 2.5mg until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
 
Dosing labetolol in ICH: Start with labetolol 20mg over 1-2 minutes and then 20mg q3-5 mins until target blood pressure is achieved and then start an infusion of 1-8mg/min.
*[[Nicardipine]] in ICH: Start at 5mg/hr, increase 2.5mg q5min until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
*[[Labetalol]] in ICH: 20mg bolus over 1-2 minutes, repeat q3-5 mins until target blood pressure is achieved and then start an infusion of 1-8mg/min.


===Reverse coagulopathy===
===Reverse coagulopathy===
====Heparin====
[[File:Harobr tICH algorithm.png|thumb|Example ''traumatic'' ICH coagulopathy reversal algorithm.]]
 
*See [[anticoagulant reversal for life-threatening bleeds]] if on a known anticoagulant (e.g. [[heparin]], [[coumadin]], [[rivaroxaban]])
*Give protamine 1mg/100units of heparin based on time since last dose
*[[Tranexamic acid]] 1g (if within 3 hours of event), followed by an additional 1g infused over 8 hours <ref>[[EBQ:CRASH-3 Trial|Crash-3 Trial]]</ref>
====[[Warfarin (Coumadin) Reversal|Warfarin]]====
{{Warfarin Reversal}}
 
====Antiplatelet====
*Includes aspirin, prasagril, clopidogrel
*Consider Desmopressin (0.3mcg/kg)
*Transfusion of platelets has been shown to increase mortality (PATCH trial)<ref>Baharoglu MI, Cordonnier C, Salman RA, et al. Platelet Transfusion Versus Standard Care After Acute Stroke due to Spontaneous Cerebral Haemorrhage Associated with Antiplatelt Therapy (PATCH): A Randomised, Open-Label, Phase 3 Trial. Lancet. 2016; 1 – 9. [Epub ahead of print]
*In traumatic brain injury, platelet transfusion has been shown  to reduce the degree of platelet inhibition, but no change in clinical outcomes<ref>Platelet Transfusion Does Not Improve Outcomes In Patients With Brain Injury On Antiplatelet Therapy Holzmacher, J.L., et al, Brain Injury 32(3):325, 2018</ref>
* Consider platelet transfusion in patients with ICH for platelet count <50,000, but many hematologists and neurosurgeons recommend platelet transfusion for ICH with platelet count < 100,000 despite lack of evidence for improved outcomes, especially if the patient requires emergency surgery


====Fondaparinux or Rivaroxaban====
====Antiplatelet Reversal====
*rFVIIa 2mg (40 mcg/kg)
''Includes [[aspirin]], [[prasugrel]], [[clopidogrel]]''
*''Or'' PCC 25-50 U/kg
*Consider [[desmopressin]] (0.3mcg/kg)
*Don't give both 2/2 to prothrombotic effects
*Platelet transfusion
====Dabigatran====
**No known thrombocytopenia: ''increases'' mortality; do '''NOT''' give<ref>[[EBQ:Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomized, open-label, phase 3 trial|(PATCH trial)]]</ref>
* Idarucizumab (Praxbind): 5 grams IV (approved as of October 2015)
**Known or diagnosed thrombocytopenia: consider if platelets <50,000
*rFVIIa 100 mcg/kg
***Some hematologists and neurosurgeons recommend for <100,000, despite lack of evidence for improved outcomes
*''Or'' 4 factor PCC 25-50 U/kg
*Consider DDAVP 0.3 mcg/kg
*Hemodialysis, if feasible

Latest revision as of 16:40, 26 February 2025

Elevating head of bed

  • 30 degree elevation will help decrease ICP by increasing venous outflow[1]

Seizure Prophylaxis and Treatment

  • Prophylactic antiepileptics not recommended[2]
  • Continuous EEG monitoring probably indicated in ICH patients with depressed mental status that is out of proportion fo degree of brain injury[3]
  • Antiepileptics indicated for clinical seizures or seizures on EEG in patients with altered mental status[4]

Blood Pressure

  • Rapid SBP lowering <140 has been advocated with early research showing improved functional outcome[5], but more recent work has found no difference between SBP <140 and <180[6]
  • SBP >200 or MAP >150
    • Consider aggressive reduction w/ continuous IV infusion
  • SBP >180 or MAP >130 and evidence or suspicion of elevated ICP
    • Consider reducing BP using intermittent or continuous IV meds to keep CPP >60-80
  • SBP >180 or MAP >130 and NO evidence or suspicion of elevated ICP
    • Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)


  • Nicardipine in ICH: Start at 5mg/hr, increase 2.5mg q5min until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
  • Labetalol in ICH: 20mg bolus over 1-2 minutes, repeat q3-5 mins until target blood pressure is achieved and then start an infusion of 1-8mg/min.

Reverse coagulopathy

Example traumatic ICH coagulopathy reversal algorithm.

Antiplatelet Reversal

Includes aspirin, prasugrel, clopidogrel

  • Consider desmopressin (0.3mcg/kg)
  • Platelet transfusion
    • No known thrombocytopenia: increases mortality; do NOT give[8]
    • Known or diagnosed thrombocytopenia: consider if platelets <50,000
      • Some hematologists and neurosurgeons recommend for <100,000, despite lack of evidence for improved outcomes
  1. ↑ http://stroke.ahajournals.org/content/38/6/2001.full
  2. ↑ AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
  3. ↑ AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
  4. ↑ AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
  5. ↑ Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013; 368:2355-2365.
  6. ↑ Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016; 1-11. [Epub ahead of print].
  7. ↑ Crash-3 Trial
  8. ↑ (PATCH trial)
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