The critical care management of spontaneous intracranial hemorrhage: a contemporary review.

Airton Leonardo De Oliveira Manoel,R Loch Macdonald,Simon Abrahamson,David Turkel-Parrella,Alberto Goffi,Thomas R Marotta,Fernando Godinho Zampieri,Abhijit Duggal

doi:10.1186/s13054-016-1432-0

Abstract

Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1432-0) contains supplementary material, which is available to authorized users.

Highlights

Spontaneous intracerebral hemorrhage (ICH) is defined as nontraumatic bleeding into the brain parenchyma [1, 2], which can extend into the ventricles and into the subarachnoid space [3]
Blood pressure targets: standard treatment (MAP = 110–130 mmHg) vs aggressive BP treatment (MAP < 110 mmHg) Maximum interval from symptom onset to treatment: 8 hours Duration of treatment: 48 hours Drugs used: – Initially, intermittent labetalol infusions (10–20 mg) – If target blood pressure was not achieved, a continuous infusion of nicardipine (5–15 mg/ hour) was started – More severe cases were treated with intravenous nicardipine from the onset – Most severe cases of hypertension were treated with sodium nitroprusside infusion at 0.3 μg/kg/minute IV infusion and titrated every few minutes to desired effect
21 patients in each group Treatment was started on average 3.2 ± 2.2 hours after symptom onset Target blood pressure was achieved within 87.1 ± 59.6 minutes in the standard group and 163.5 ± 163.8 minutes in the aggressive BP treatment group No significant differences in early neurological deterioration, hematoma and edema growth, and clinical outcome at 90 days

Summary

Introduction

Spontaneous intracerebral hemorrhage (ICH) is defined as nontraumatic bleeding into the brain parenchyma [1, 2], which can extend into the ventricles and into the subarachnoid space [3]. ICH is the second most common subtype of stroke [3], accounting for 10–50 % of all cases [4, 5], depending on the population, race, and region studied [6]. Recent observational reports suggested that self-fulfilling prognostic pessimism may lead to withdrawal of life support in patients who otherwise may have had an acceptable clinical outcome if managed aggressively [11]. Part of the pessimism surrounding the prognostication of hemorrhagic stroke is hypothesized to be a tendency not to consider de Oliveira Manoel et al Critical Care (2016) 20:272 factors such as age, previous comorbidities, etiology of the bleeding, and socioeconomic factors [12], which are known to affect outcome [16]

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