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Intracerebral Hemorrhage, Emergency Medicine

Basics

Description

- Uncontrolled or acute HTN (most common) - Vascular malformations: - Arteriovenous malformation - Venous angiomas - Ruptured cerebral aneurysms

- Lobar hemorrhage (30%): - Variable signs depending on involved area

- Cerebellar hemorrhage (15%): - Thalamic hemorrhage (10%): - Similar to putamen, but may also have eye movement abnormalities

- Caudate hemorrhage (5%): - Confusion - Memory loss - Hemiparesis - Gaze paresis

- Pontine hemorrhage (5%): - Quadriplegia - Pinpoint pupils - Ataxia - Sensorimotor loss

- CT angiography: - Gaining increasing acceptance as a diagnostic tool in acute setting - Up to 15% of patients may show an underlying vascular etiology on CTA, potentially changing acute management - Contrast extravasation (spot sign) may represent ongoing bleeding - Highest risk of hematoma expansion with poor outcome and mortality

- Traumatic hemorrhage: - Subarachnoid hemorrhage - Subdural hematoma - Epidural hematoma

- Treatment of elevated ICP: - Controlled ventilation to PaCO2 of 35 Torr - Fluid restriction; elevate head of bed 30 ° - Mannitol-osmotic diuresis - Use furosemide as an alternative

Hemorrhage into brain parenchyma:

  • Compression of brain tissues
  • Secondary injury results from:Cerebral edemaIncreased intracranial pressure (ICP)Potential of brain herniation

Etiology

Intracerebral hemorrhage can occur spontaneously or from trauma:

  • Uncontrolled or acute HTN (most common)
  • Vascular malformations:Arteriovenous malformationVenous angiomasRuptured cerebral aneurysms
  • Neoplasm (particularly melanoma and glioma)
  • Anticoagulant therapy (warfarin, heparin)
  • Thrombolytic agents
  • Illicit drugs (cocaine, amphetamines)
  • Bleeding disorders (hemophilia)
  • Cerebral amyloid angiopathy
  • Traumatic hemorrhage secondary to blunt or penetrating injury

Diagnosis

Signs and Symptoms

History

  • Severe headache, typically sudden in onset
  • Seizure
  • Evidence of head injury
  • Neck stiffness
  • Vomiting
  • Anticoagulation therapy
  • Altered level of consciousness (may be comatose):Altered mental status may occur as late as 24-48 hr after head injury

Physical Exam

  • HTN
  • Nuchal rigidity
  • Altered mental status
  • Variable neurologic deficits depending on site of intracerebral hemorrhage:Putamen hemorrhage (35%):Contralateral hemiparesisContralateral hemisensory lossOccasional dysphagiaOccasional neglectLobar hemorrhage (30%):Variable signs depending on involved areaCerebellar hemorrhage (15%):Thalamic hemorrhage (10%):Similar to putamen, but may also have eye movement abnormalitiesCaudate hemorrhage (5%):ConfusionMemory lossHemiparesisGaze paresisPontine hemorrhage (5%):QuadriplegiaPinpoint pupilsAtaxiaSensorimotor loss

Essential Workup

  • Manage airway if indicated
  • Immediate noncontrast head CT:Acute hemorrhage appears as high-density lesion

Diagnosis Tests & Interpretation

Lab

  • CBC
  • Coagulation studies (PT/PTT, INR, platelets)
  • Electrolytes; BUN, creatinine
  • Pregnancy test in women of childbearing age
  • EKG
  • Consider toxicology screen

Imaging

  • CT as above
  • MRI may be useful but currently not as available or rapid as CT

Diagnostic Procedures/Surgery

  • CT angiography:Gaining increasing acceptance as a diagnostic tool in acute settingUp to 15% of patients may show an underlying vascular etiology on CTA, potentially changing acute managementContrast extravasation (spot sign) may represent ongoing bleedingHighest risk of hematoma expansion with poor outcome and mortality

Differential Diagnosis

  • Seizure:
  • CNS infection
  • CNS mass
  • Electrolyte or acid-base abnormality
  • Intoxication
  • Wernicke encephalopathy
  • Migraine headache
  • Transient ischemic attack
  • Nonhemorrhagic acute cerebrovascular accident
  • Air embolism
  • Differential diagnosis once bleed is seen on CT:Spontaneous hemorrhage:Hypertensive hemorrhageArteriovenous malformationNeoplasmTraumatic hemorrhage:Subarachnoid hemorrhageSubdural hematomaEpidural hematoma

Additional differential diagnoses include:

  • Moyamoya disease
  • Acute infantile hemiplegia

Treatment

Pre-Hospital

  • C-spine precautions if head or neck injury is suspected
  • Elevation of head with C-spine control
  • Initial pre-hospital responder must ascertain neurologic defect to be able to note progression of symptoms

Initial Stabilization/Therapy

  • Manage airway and resuscitate as needed:Patients with depressed level of consciousness should be intubated immediately for controlled ventilation
  • Early neurosurgical consultation

Ed Treatment/Procedures

  • Prompt neurosurgery and/or neurology consultation
  • BP management:Must use caution in BP control because acute lowering of BP to normal in setting of increased ICP could reduce cerebral perfusion to ischemic levelsUse labetalol, nicardipine, esmolol, enalapril to lower diastolic BP initially by 10%Normotensive levels should be achieved over 12-24 hrMay use nitroprusside, nitroglycerin, or hydralazine as an alternative
  • Treatment of elevated ICP:Controlled ventilation to PaCO2 of 35 TorrFluid restriction; elevate head of bed 30 °Mannitol-osmotic diuresisUse furosemide as an alternative
  • Correct coagulopathies:Consider fresh frozen plasma (FFP), platelets, prothrombin complex concentrates, vitamin K
  • Consider anticonvulsants

Medication

  • Esmolol: 0.5-1 mg/kg initial bolus IV, followed by 50-150 μg/kg/min infusion
  • Enalapril: 1.25-5 mg q6h (risk of precipitous BP lowering, test dose 0.625 mg)
  • FFP: 10-20 mL/kg IV
  • Fosphenytoin: 15-20 mg/kg phenytoin equivalents (PE) at rate of 100-150 mg/min IV/IM
  • Furosemide: 20-40 mg (peds: 0.5-1 mg/kg/dose) IV; may repeat as necessary
  • Hydralazine: 10-40 mg (peds: 0.1-0.2 mg/kg/dose; max. 20 mg/dose) IV; may repeat as necessary
  • Labetalol: 20 mg (peds: 0.3-1 mg/kg/dose; max. 20 mg/dose) IV; may give additional 40-80 mg IV q10min to max. 300 mg
  • Mannitol: 1 g/kg IV
  • Nicardipine: 5-15 mg/h infusion
  • Nitroprusside: Start 0.25-10 μg/kg/min IV (max. 10 μg/kg/min); titrate to effect
  • Phenytoin: 15-20 mg/kg/dose (peds: 15 mg/kg) at rate of <40-50 mg/min
  • Platelet: 1-2 U IV in consultation with neurosurgery
  • Prothrombin complex concentrates: 500-1,000 IU IV
  • Vitamin K: 5-10mg IV over 30 min

Follow-Up

Disposition

Admission Criteria

  • To OR if surgical intervention is indicated
  • To ICU if intubated, altered level of consciousness, or on IV infusion for BP control
  • Admit to neurologic observation unit if normal neurologic exam without evidence of progression of bleed and hemodynamically stable

Discharge Criteria

All patients with intracerebral hemorrhage should be admitted

Issues for Referral

Rehabilitation is a key aspect of recovery

Follow-Up Recommendations

  • Treating HTN in the nonacute setting is the most important step to reduce the risk of intracerebral hemorrhage
  • Discontinuation of smoking, alcohol use, and cocaine use prevents recurrence of intracerebral hemorrhage

Pearls and Pitfalls

  • Brain imagining is a crucial part of emergent evaluation of patients with headache, HTN, and/or altered level of consciousness
  • Cautious BP control because acute lowering of BP to normal in setting of ICP could reduce cerebral perfusion to ischemic levels
  • Consider delayed intracranial bleed in patients on anticoagulation with head trauma

Additional Reading

  • Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: A guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38:2001-2023.
  • Caceres JA, Goldstein JN. Intracranial hemorrhage. Emerg Med Clin North Am. 2012;30:771-794.
  • Naval NS, Nyguist PA, Carhuapoma JR. Management of spontaneous intracerebral hemorrhage. Neurol Clin. 2008;26:373-384.
  • Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59:460-468.
  • Nishijima DK, Offerman SR, Ballard DW, et al. Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. Acad Emerg Med. 2013;20:140-145.

See Also (Topic, Algorithm, Electronic Media Element)

  • Headache
  • Hypertensive Emergencies
  • Seizure

Codes

ICD9

  • 431 Intracerebral hemorrhage
  • 853.00 Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness

ICD10

  • I61.9 Nontraumatic intracerebral hemorrhage, unspecified
  • S06.360A Traum hemor cereb, w/o loss of consciousness, init

SNOMED

  • 274100004 Cerebral hemorrhage (disorder)
  • 450418003 cerebral hemorrhage following injury (disorder)
  • 291571000119106 Spontaneous cerebral hemorrhage (disorder)