Intracerebral Hemorrhage

-- SX: Sudden onset focal neurologic deficit with
-- Hx:hypertension, mycotic aneurysm from endocarditis, bleeding disorder, vasculitis, brain tumor, Substance use (e.g., methamphetamine, cocaine)
-- initial data:
-- PE: Neurologic exam
-- W/U: CTH/CTA, CBC,BMP,Coags,type&screen
-- MEDS: AC?
-- DDX/Causes: Hypertensive vasculopathy (arteriolosclerosis), Cerebral amyloid angiopathy, Vascular malformations, Hemorrhagic conversion of ischemic stroke, Coagulopathy / anticoagulation, Tumor, Substance use (e.g., methamphetamine, cocaine)
-- Calculated ICH score is predicting a mortality rate of
-- Patient has the following risk factors for poor prognosis: *** hematoma growth within initial 48 hours, interventricular and subarachnoid extension, early neurologic deterioration, use of oral anticoagulant

Plan

  • ICH order set applied

  • Neurosurgery consulted

  • Nicardipine drip and labetalol 10 mg IV PRN for systolic blood pressure goal of 130-<150 

  • Neuro check per ICH protocol (q15m x2h, then q30m x6h, then q1h x16h

  • Keep euglycemia 140-180 mg/dL, insulin ggt prn

  • Keep Normonatremia goal >140 consider 3% 250–500 mL bolus then 50 mL/hr gtt check Na level q4h

  • Keep euvolemia NS if needed ( strict I/O)

  • Keep euthermia prn tylenol 

  • Discontinue all AP and AC and Reversal if needed 

  • SCDs for DVT prophylaxis

  • Repeat CT scan if any signs of neurological deterioration

  • PT/OT/SLP

  • STAT Head CT/CTA if change in neuro exam (ie. s/s incr ache + significant new change in NIHSS) 

  • Headache: scheduled tylenol, could consider nortriptyline 10–25 mg qHS over opioids (masking neuro changes)

  • If cute seizure Consider cEEG and Neuro consult , Ativan 4 mg IV, repeat q5 min (max ~8 mg), then load 60 mg/kg (up to ~4500 mg IV once) then 1000 mg BID

  • Monitor airway management (Intubation if GCS less than 8)

  • contact NSG if patient shows signs of increase ICP (herniation risk) ((decreased GCS or rapidly worsening mental status, a unilateral blown (dilated, nonreactive) pupil, posturing, and Cushing triad (hypertension, bradycardia, and irregular respirations)), lower ICP immediately (minutes matter) use 3% saline as above, Mannitol is option1 g/kg followed by infusion of 0.25-.5 g/kg every 6 hours with goal plasma osmolality of 300-310 (use when Hemodynamically stable, and good kidneys)

  • If ICP monitoring goal CPP (MAP − ICP) of 60 to 70, vasopressors such as phenylephrine or norepinephrine can be used to augment MAP to maintain such CPP, EVD placed to gravity, ***cmH2O above tragus

  • Hyperventilation with goal PaCO2 of 25 to 30

  • start decadron 4 mg q 6 h Only if vasogenic edema 2/2 (Tumor-Related) Hemorrhage  e.g., hemorrhagic metastasis ( not in Primary (Spontaneous) ICH 5–7 days while monitoring symptoms and MRI findings. (4 mg every 6 hours for 3 days, then decrease to 4 mg every 8 hours for 2–3 days, then 4 mg every 12 hours for 2–3 days, and finally 2 mg every 12 hours for 2–3 days.)

Note

  • MRV when ICH pattern or patient profile suggests cerebral venous sinus thrombosis — e.g., lobar/atypical bleed, young or postpartum patient, hypercoagulable state, or unexplained venous infarct pattern

  • CBC

  • CMP

  • Mg, Phos

  • PT/INR, PTT

  • Type & screen

  • Troponin + ECG

  • Glucose

  • ± Toxicology / alcohol level

  • STATCT head: confirms bleed and complications

  • CTA: finds cause and active bleeding

  • Repeat CT: checks for worsening

  • MRI: finds underlying cause

  • MRV: looks for venous clot (CVST)

  • Nicardipine drip (first-line)

  • Labetalol IV PRN

  • SBP goal: 130–150

  • Hold ALL AC/AP

  • Reverse if needed:

  • HOB 30°, neck midline

  • Seizures (if present)

  • Ativan 2–4 mg IV (repeat once if needed)

  • Load Keppra (1–3 g IV or ~60 mg/kg)

  • Maintenance 500–1000 mg BID

  • Consider cEEG if persistent AMS

  • Euglycemia: 140–180 (insulin PRN)

  • Normonatremia ≥14

    • Consider 3% saline infusion

    • Na checks q4h

  • Euvolemia: NS, strict I/O

  • Euthermia: Tylenol PRN

  • DVT prophylaxis

  • SCDs immediately

  • Steroids (ONLY if tumor-related)

    • Neurosurgery consult (early)

  • Neurology consult

  • Neuro checks:

    • q15 min × 2h → q30 min × 6h → q1h

  • Telemetry

  • Strict I/O

  • Consider A-line