Intracerebral Hemorrhage (ICH)

Management

Intubation may be required for airway protection. However two thirds of patients won't require intubation.
There are no validated or well-defined criteria for intubation – this is a clinical judgement based on examination and trajectory.
Care is required to avoid stimulation and hypertension, which could worsen intracranial pressure elevation
See Intubation of the Neurocritical Care Patient

2022 AHA/ASA: In patients with an initial systolic BP of 150-220, acute lowering to target a systolic BP of 130-150 mm may be reasonable. However, lowering the blood pressure below <130 mm is potentially harmful and should be avoided
- Benefit from antihypertensives is maximized if they are started immediately (when the risk of hematoma expansion is greatest).
- The optimal duration of blood pressure control is not known. Theoretically, benefit would be expected to extend through the period when there is a high risk of hemorrhage expansion (e.g., perhaps the first ~24 hours in patients without coagulopathy). Gradual transition to oral antihypertensives may be reasonable after >24 hours, among patients who have stabilized
ATACH-II (NEJM 2016): in patients with spontaneous ICH (parenchymal hemorrhage) and hypertension with SBP > 180 at least once, a lower BP goal (110 to 139, mean SBP 129 mmHg) within the first 24 hours did not demonstrate and clinical benefit vs standard of care (140 to 180, mean SBP 141 mmHg), and may increase renal adverse effects
- excluded SAH, traumatic ICH, aneurysmal bleed, SDH

Convulsive seizures occur in ~10% of patients, but the rate of subclinical seizures may be substantially higher
Risk factors for seizures
- Cortical involvement (e.g., lobar hemorrhages).
- Coexistence of subarachnoid and/or subdural hemorrhage.
- Complications, including rebleeding.
Indications for continuous EEG:
- Impaired consciousness that is out of proportion to what would be expected based on the CT scan
- Unexplained fluctuations in mental status
- Any history or clinical signs of seizure
Management
- Seizure prophylaxis isn't recommended.
- Antiepileptic therapy is indicated for a patient with witnessed seizure, electroencephalographic seizure, or nonconvulsive status epilepticus

avoid fever/hyperthermia
DVT prophylaxis: initially use IPCs, then start low dose LMWH or UFH at 24-48 hours from ICH onset after serial CTs show stability of the hemorrhage
- Patients with underlying coagulopathy or imaging evidence of ongoing hemorrhage expansion may require a more personalized approach.
Formal dysphagia screening prior to initiation of oral intake
sodium management
- Avoid hyponatremia or rapid decreases in sodium
- Routine use of hypertonic saline isn't supported by evidence
- Boluses of hypertonic saline or hypertonic bicarbonate may be used to manage elevated intracranial pressure, ideally as a bridge to more definitive therapy (e.g., an external ventricular drain).