Template:ICH Treatment
Elevating head of bed
- 30 degree elevation will help decrease ICP[1]
Blood Pressure
- Few studies on optimal management however many 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[2], but more recent work has found no difference between SBP <140 and <180[3]
- 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)
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.
Reverse coagulopathy
Heparin
- Give protamine 1mg/100units of heparin based on time since last dose
Warfarin
- Stop warfarin
- Give Vitamin K 5-10mg IV INR will decrease over 24-48 hours (small risk of anaphylaxis with IV Vitamin K)
- Give 4 Factor prothrombin complex concentrate (PCC)
- If no PCC, then give 15 ml/kg fresh frozen plasma (no benefit to combining PCC and FFP)
Antiplatelet
- Includes aspirin, prasagril, clopidogrel
- Consider Desmopressin (0.3mcg/kg)
- Transfusion of platelets has been shown to increase mortality (PATCH trial)[4]
- 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
- rFVIIa 2mg (40 mcg/kg)
- Or PCC 25-50 U/kg
- Don't give both 2/2 to prothrombotic effects
Dabigatran
- Idarucizumab (Praxbind): 5 grams IV (approved as of October 2015)
- rFVIIa 100 mcg/kg
- Or 4 factor PCC 25-50 U/kg
- Consider DDAVP 0.3 mcg/kg
- Hemodialysis, if feasible
- ↑ http://stroke.ahajournals.org/content/38/6/2001.full
- ↑ 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.
- ↑ 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].
- ↑ 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]