Intracerebral Hemorrhage, Emergency Medicine

Basics

Description

Hemorrhage into brain parenchyma:

Compression of brain tissues
Secondary injury results from:
- Cerebral edema
- Increased 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 malformation
- Venous angiomas
- Ruptured 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 hemiparesis
  - Contralateral hemisensory loss
  - Occasional dysphagia
  - Occasional neglect
- Lobar hemorrhage (30%):
  - Variable signs depending on involved area
- Cerebellar hemorrhage (15%):
  - Vomiting
  - Ataxia
  - Nystagmus
- 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

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 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

Differential Diagnosis

Seizure:
- Todd paralysis
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 hemorrhage
  - Arteriovenous malformation
  - Neoplasm
- Traumatic hemorrhage:
  - Subarachnoid hemorrhage
  - Subdural hematoma
  - Epidural 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 levels
- Use labetalol, nicardipine, esmolol, enalapril to lower diastolic BP initially by 10%
- Normotensive levels should be achieved over 12-24 hr
- May use nitroprusside, nitroglycerin, or hydralazine as an alternative
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
Correct coagulopathies:
- Consider fresh frozen plasma (FFP), platelets, prothrombin complex concentrates, vitamin K
Consider anticonvulsants
- Phenytoin, fosphenytoin

Medication

Esmolol: 0.5-1 mg/kg initial bolus IV, followed by 50-150 Î¼g/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 Î¼g/kg/min IV (max. 10 Î¼g/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.

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)

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