Coagulopathy is a rare etiology of SAH: it is more commonly associated with intracerebral hemorrhage and subdural hematoma than with subarachnoid hemorrhage (see Subdural Hematoma and Subarachnoid Hemorrhage)
In General, Coumadin-Related Intracerebral Hemorrhage is Associated with Increased Hematoma Volume, Greater Risk of Expansion, and Increased Morbidity/Mortality
Coumadin Did Not Increase the Initial Intracerebral Hemorrhage Volume, But Did Increase the Risk of In-Hospital Hematoma Expansion (Neurology, 2004) [MEDLINE]
Anticoagulation-Associated Intracerebral Hemorrhage Appears to Preferentially Involve the Cerebellum (Neurocrit Care, 2006) [MEDLINE]
Rapid Neuroimaging with Head CT/Brain MRI is Recommended to Distinguish Ischemic Stroke from ICH (Class I, Level of Evidence A)
Use of Contrast Imaging Studies
CT Angiogram/Contrast-Enhanced CT May be Considered to Identify Patients at Risk for Hematoma Expansion (Class IIb; Level of Evidence B)
CT Angiogram/CT Venography/Contrast-Enhanced CT/Contrast-Enhanced MRI/Magnetic Resonance Angiography/Magnetic Resonance Venography/Catheter Angiography Can Be Useful to Evaluate for Underlying Structural Lesions Including Vascular Malformations and Tumors When There is Clinical or Radiologic Suspicion (Class IIa, Level of Evidence B)
Rapid Neuroimaging with CT or MRI is Recommended to Distinguish Ischemic Stroke from ICH (Class I, Level of Evidence A)
Use of Contrast Imaging Studies
CT Angiogram/Contrast-Enhanced CT May be Considered to Identify Patients at Risk for Hematoma Expansion (Class IIb; Level of Evidence B)
CT Angiogram/CT Venography/Contrast-Enhanced CT/Contrast-Enhanced MRI/Magnetic Resonance Angiography/Magnetic Resonance Venography/Catheter Angiography Can Be Useful to Evaluate for Underlying Structural Lesions Including Vascular Malformations and Tumors When There is Clinical or Radiologic Suspicion (Class IIa, Level of Evidence B)
Continuous EEG Monitoring is Probably Indicated in Patients with Depressed Mental Status Which is Out of Proportion to the Degree of Brain iInjury (Class IIa, Level of Evidence C)
Systematic Screening for Myocardial Ischemia/Infarction with Electrocardiogram and Cardiac Enzyme Testing After ICH is Reasonable (Class IIa, Level of Evidence C)
Systematic Screening for Myocardial Ischemia/Infarction with Electrocardiogram and Cardiac Enzyme Testing After ICH is Reasonable (Class IIa, Level of Evidence C)
Clinical Manifestations
Clinical Classification
Clinical Scoring Using the Intracerebral Hemorrhage (ICH) Score (Stroke, 2001) [MEDLINE]
Factors in the Intracerebral Hemorrhage (ICH) Score
Age >80 y/o: 1 point
Glasgow Coma Score (GCS)
GCS 3-4: 2 points
GCS 5-12: 1 points
GCS 13-15: 0 points
Infratentorial Origin of Intracerebral Hemorrhage: 1 point
Ischemic EKG Changes Occur in 41% of Cases, However, Myocardial Injury (as Documented by Elevated Troponin Levels) was Observed in Only 12% of Cases (Am J Emerg Med, 2012) [MEDLINE]
After Controlling for Age/Risk Factors, Ischemic Changes Predicted Myocardial Injury (Am J Emerg Med, 2012) [MEDLINE]
Ischemic Changes in Lead I/AVL and V5-V6 were More Specific for Myocardial Injury (Am J Emerg Med, 2012) [MEDLINE]
Prolonged QT (see Torsade): QT prolongation is common in intracerebral hemorrhage (occurs in 64% of cases)
Fever is a Common After Brain Injury (Due to Traumatic Brain Injury, Ischemic CVA, and/or Intracerebral Hemorrhage) (J Intensive Care Med, 2015) [MEDLINE]
Fever is a Risk Factor for In-Hospital Mortality (J Intensive Care Med, 2015) [MEDLINE]
Initial Monitoring and Management of Should Occur in an Intensive Care Unit or Dedicated Stroke Unit with Physician/Nursing with Neuroscience Acute Care Expertise (Class I, Level of Evidence B)
Prediction of Outcome
Aggressive Care Early After the Onset of Intracerebral Hemorrhage and Postponement of New DNR Orders Until at Least the Second Full Day of Hospitalization is Probably Recommended (Class IIa, Level of Evidence B)
Patients with Preexisting DNR Orders are Not Included in this Recommendation
Current Prognostic Models for Individual Patients Early After Intracerebral Hemorrhage are Biased by the Failure to Account for the Influence of Withdrawal of Support and Early DNR Orders (Class III, Level of Evidence C)
DNR Status Should Not Limit Appropriate Medical/Surgical Interventions Unless Otherwise Explicitly Indicated (Class III, Level of Evidence C)
Blood Pressure Management
Clinical Efficacy
Australian INTERACT2 Randomized Trial of Blood Pressure Management in Intracerebral Hemorrhage (NEJM, 2013): n = 2794
Intensive Lowering of Systolic Blood Pressure (to <140 mm Hg) Did Not Result in a Significant Decrease in Mortality Rate or Rate of Severe Disability, as Compared to Guideline-Recommended Lowering of Systolic Blood Pressure (to <180 mm Hg)
However, Ordinal Analysis of Modified Rankin Scores Indicated that Intensive Lowering of Systolic Blood Pressure Resulted in Improved Functional Outcomes
For Patients Presenting with SBP 150-220 mm Hg and Without Contraindication to Acute BP Treatment, Acute Lowering of SBP to 140 mm Hg is Safe (Class I, Level of Evidence A) and Can Be Effective for Improving the Functional Outcome (Class IIa, Level of Evidence B)
For Patients Presenting with SBP >220 mm Hg, it May Be Reasonable to Consider Aggressive Reduction of BP with a Continuous Intravenous Antihypertensive Infusion and Frequent BP Monitoring (Class IIb, Level of Evidence C)
Blood Pressure Management to Prevent Recurrent Intracerebral Hemorrhage
BP Should Be Controlled in All ICH Patients to Prevent Recurrent ICH (Class I, Level of Evidence A)
Measures to Control BP to Prevent Recurrent ICH Should Begin Immediately After the Onset of ICH (Class I, Level of Evidence A)
Management of Coagulopathy
Clinical Efficacy-Reversal of Coumadin Anticoagulation
Pooled Analysis of Reversal Strategies for Coumadin Anticoagulation (Ann Neurol, 2015) [MEDLINE]
Combination of Fresh Frozen Plasma (FFP) and Prothrombin Complex Concentrate (PCC) Might Be Associated with the Lowest Case Fatality in Reversal of Coumadin Anticoagulation
Fresh Frozen Plasma (FFP) Might Be Equivalent to Prothrombin Complex Concentrate (PCC): randomized trials are required to determine the most effective treatment
Patients with Severe Thrombocytopenia Should Receive Platelets (Class I, Level of Evidence C)
Management of Antiplatelet Agents
Usefulness of Platelet Transfusions in Patients with a History of Antiplatelet Agent Use is Uncertain (Class IIb, Level of Evidence C)
Management of Coumadin Anticoagulation (see Coumadin)
Patients with Elevated INR (Due to Coumadin) Should Have Coumadin Withheld and Receive Therapy to Replace the Vitamin K–Dependent Coagulation Factors to Correct the INR and Receive Intravenous Vitamin K (Class I, Level of Evidence C)
Prothrombin Complex Concentrates (PCC) May Have Fewer Complications and Correct the INR More Rapidly than FFP and Might Be Considered Over FFP (Class IIb, Level of Evidence B)
rFVIIa Does Not Replace All Clotting Factors, and Although the INR May Be Lowered, Clotting May Not Be Restored In Vivo
Therefore, rFVIIa is Not Recommended for Coumadin Reversal in ICH (Class III, Level of Evidence C)
For Patients Who are Taking Dabigatran/Rivaroxaban/Apixaban, Treatment with FEIBA (Factor Eight Inhibitor Bypassing Activity), Other Prothrombin Complex Concentrates (PCC), or rFVIIa Might Be Considered on an Individual Basis (Class IIb, Level of Evidence C)
Activated Charcoal Might Be Used if the Most Recent Dose of Dabigatran/Rivaroxaban/Apixaban was Taken <2 hrs Earlier (Class IIb, Level of Evidence C)
Hemodialysis Might Be Considered for Dabigatran (Class IIb, Level of Evidence C)
Other
Although rFVIIa Can Limit the Extent of Hematoma Expansion in Noncoagulopathic Patients with ICH, Due to Thromboembolic Risk and No Clear Clinical Benefit in Unselected Patients, rFVIIa is Not Recommended (Class III, Level of Evidence A)
TICH-2 RandomiZed, Placebo-Controlled, Phase 3 Superiority Trial of Tranexamic Acid for Hyperacute Primary IntraCerebral Hemorrhage (Lancet, 2018) [MEDLINE]
Functional status 90 days after intracerebral haemorrhage did not differ significantly between patients who received tranexamic acid and those who received placebo, despite a reduction in early deaths and serious adverse events
Larger randomised trials are needed to confirm or refute a clinically significant treatment effect
Patients with a GCS ≤8, Those with Clinical Evidence of Transtentorial Herniation, or Those with Significant Intraventricular Hemorrhage of Hydrocephalus Might Be Considered for ICP Monitoring and Treatment (Class IIb, Level of Evidence C)
CPP of 50-70 mm Hg May Be Reasonable to Maintain Depending on the Status of Cerebral Autoregulation (Class IIb, Level of Evidence C)
Ventricular Drainage as a Treatment for Hydrocephalus is Reasonable, Especially in Patients with a Decreased Level of Consciousness (Class IIa, Level of Evidence B)
Corticosteroids Should Not Be Administered for the Treatment of Elevated ICP in the Setting of ICH (Class III, Level of Evidence B)
Although Intraventricular Administration of rtPA in Intraventricular Hemorrhage Appears to Have a Fairly Low Complication Rate, the Efficacy and Safety of This Treatment is Uncertain (Class IIb, Level of Evidence B)
Efficacy of Endoscopic Treatment of Intraventricular Hemorrhage is Uncertain (Class IIb, Level of Evidence B)
Patients with Cerebellar Hemorrhage Who are Deteriorating Neurologically or Who Have Brainstem Compression and/or Hydrocephalus from Ventricular Obstruction Should Undergo Surgical Evacuation of the Hemorrhage as Soon as Possible (Class I, Level of Evidence B)
Initial Treatment of These Patients with Ventricular Drainage, Rather than Surgical Evacuation is Not Recommended (Class III, Level of Evidence C)
Supratentorial Intracerebral Hemorrhage
For Most Patients with Supratentorial Intracerebral Hemorrhage, the Usefulness of Surgery is Not Well Established (Class IIb, Level of Evidence A)
A Policy of Early Hematoma Evacuation is Not Clearly Beneficial, as Compared to Hematoma Evacuation When Patients Deteriorate (Class IIb, Level of Evidence A)
Supratentorial Hematoma Evacuation in Deteriorating Patients Might Be Considered as a Life-Saving Measure (Class IIb, Level of Evidence C)
Decompressive Craniectomy with/without Hematoma Evacuation Might Decrease the Mortality Rate for Patients with Supratentorial Intracerebral Hemorrhage Who are in a Coma, Have Large Hematomas with Significant Midline Shift, or Have Elevated ICP Refractory to Medical Management (Class IIb, Level of Evidence C)
The Effectiveness of Minimally Invasive Clot Evacuation with Stereotactic or Endoscopic Aspiration with/without Thrombolytic Administration is Uncertain (Class IIb, Level of Evidence B)
Clinical Seizures Should Be Treated with Antiseizure Medications (Class I, Level of Evidence A)
Patients with a Change in Mental Status Who are Found to Have Electroencephalographic Seizures (i.e. Non-Convulsive Status Epilepticus) Should Be Treated with Antiseizure Medications (Class I, Level of Evidence C)
Continuous EEG Monitoring is Probably Indicated in Patients with Depressed Mental Status Which is Out of Proportion to the Degree of Brain iInjury (Class IIa, Level of Evidence C)
Prophylactic Antiseizure Medication is Not Recommended (Class III, Level of Evidence B)
Glucose Should Be Monitored (Class I, Level of Evidence C)
Both Hypoglycemia/Hyperglycemia Should Be Avoided (Class I, Level of Evidence C)
Respiratory Management
Clinical Efficacy-Early Tracheostomy (see Tracheostomy)
Randomized SETPOINT2 Trial of Early Tracheostomy in Severe Acute Ischemic/Hemorrhagic Cerebrovascular Accident (CVA) (JAMA, 2022) [MEDLINE]: n = 366
Tracheostomy (Predominantly Percutaneously) was Performed in 95.2% of the Early Tracheostomy Group at a Median of 4 Days After Intubation (Interquartile Range: 3-4 Days) and in 67% of the Control Group at a Median of 11 Days After Intubation (Interquartile Range: 10-12 Days)
The Proportion without Severe Disability (Modified Rankin Scale Score: 0-4) at 6 Months was Not Significantly Different in the Early Tracheostomy vs the Control Group (43.5% vs 47.1%; Difference: −3.6%; 95% CI: −14.3% to 7.2%]; Adjusted Odds Ratio 0.93; 95% CI: 0.60-1.42]; P = 0.73)
Of the Serious Adverse Events (Related to Tracheostomy), Rates were 5.0% in the Early Tracheostomy Group vs 3.4% in the Control Group
Conclusion
In Patients with Severe Ischemic/Hemorrhagic Stroke Requiring Invasive Mechanical Ventilation, a Early Tracheostomy Did Not Significantly Improve the Survival Rate without Severe Disability at 6 Months, as Compared to Standard Approach to Tracheostomy
However, the Wide Confidence Intervals Around the Effect Estimate May Include a Clinically Important Difference (Therefore, a Clinically Relevant Benefit or Harm from Early Tracheostomy Cannot Be Excluded)
Formal Screening for Dysphagia Should Be Performed in All Patients Before the Initiation of Oral Intake to Decrease the Risk of Pneumonia (Class I, Level of Evidence B)
Venous Thromboembolism Prophylaxis/Management (see MEDLINE]: n = 31 trials No Significant Relationship Between Statin Use and the Risk of Intracerebral Hemorrhage
Risk Stratification for Recurrence of Intracerebral Hemorrhage When Stratifying a Patient’s Risk for Recurrent Intracerebral Hemorrhage May Affect Management Decisions, it is Reasonable to Consider the Following Risk Factors for Intracerebral Hemorrhage Recurrence (Class IIa, Level of Evidence B) Lobar Location of the Initial Intracerebral Hemorrhage Older Age Presence and Number of Microbleeds on Gradient Echo MRI Ongoing Anticoagulation Presence of Apolipoprotein E ε2 or ε4 Alleles
Blood Pressure Control
BP Should Be Controlled in All ICH Patients to Prevent Recurrent Intracerebral Hemorrhage (Class I, Level of Evidence A)
Measures to Control BP to Prevent Recurrent ICH Should Begin Immediately After the Onset of ICH (Class I, Level of Evidence A)
Long-Term Goal of Systolic BP <130 mm Hg and Diastolic BP <80 mm Hg is Reasonable (Class IIa, Level of Evidence B)
Lifestyle Modifications
Avoidance of Alcohol Use >2 Drinks Per Day, Tobacco Use, and Illicit Drug Use are Probably Beneficial (Class IIa, Level of Evidence B)
Treatment of Obstructive Sleep Apnea, are Probably Beneficial (Class IIa, Level of Evidence B)
Anticoagulation Considerations
Avoidance of Long-Term Anticoagulation with Coumadin as a Treatment for Nonvalvular Atrial Fibrillation is Probably Recommended After Coumadin-Associated Spontaneous Lobar Intracerebral Hemorrhage Because of the Relatively High Risk of Recurrence (Class IIa, Level of Evidence B)
Anticoagulation After Nonlobar ICH and Antiplatelet Monotherapy After Any Intracerebral Hemorrhage Might Be Considered, Particularly When There are Strong Indications for These Agents (Class IIb; Level of Evidence B)
The Optimal Timing to Resume Oral Anticoagulation After Anticoagulant-Related Intracerebral Hemorrhage is Uncertain
Avoidance of Oral Anticoagulation for at Least 4 wks (in Patients without Mechanical Heart Valves) Might Decrease the Risk of Intracerebral Hemorrhage Recurrence (Class IIb, Level of Evidence B)
If Indicated, Aspirin Monotherapy Can Probably Be Restarted in the Days After Intracerebral Hemorrhage, Although the Optimal Timing is Uncertain (Class IIa, Level of Evidence B)
The Usefulness of Dabigatran/Rivaroxaban/Apixaban in Patients with Atrial Fibrillation and Past Intracerebral Hemorrhage to Decrease the Risk of Recurrence is Uncertain (Class IIb, Level of Evidence C)
There are Insufficient Data to Recommend Restrictions on the Use of Statins in ICH Patients (Class IIb, Level of Evidence C)
Prognosis
Clinical Scoring Using the Intracerebral Hemorrhage (ICH) Score (Stroke, 2001) [MEDLINE]
Factors in the Intracerebral Hemorrhage (ICH) Score
Age >80 y/o: 1 point
Glasgow Coma Score (GCS)
GCS 3-4: 2 points
GCS 5-12: 1 points
GCS 13-15: 0 points
Infratentorial Origin of Intracerebral Hemorrhage: 1 point
Presence of Intraventricular Hemorrhage: 1 point
Outcome
ICH = 0: 100% survival
ICH = 5: 0% survival
30-Day Mortality Rate was Correlated with the ICH Score
References
General
Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Neurology. 2004;63:1059–1064 [MEDLINE]
Location and outcome of anticoagulant-associated intracerebral hemorrhage. Neurocrit Care. 2006;5:197– 201. doi: 10.1385/NCC:5:3:197 [MEDLINE]
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069. Epub 2015 May 28 [MEDLINE]
Diagnosis
xxxx
Clinical
General
The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001 Apr;32(4):891-7 [MEDLINE]
Brain injury as a risk factor for fever upon admission to the intensive care unit and association with in-hospital case fatality: a matched cohort study. J Intensive Care Med. 2015 Feb;30(2):107-14. doi: 10.1177/0885066613508266. Epub 2013 Oct 16 [MEDLINE]
Ischemic-appearing electrocardiographic changes predict myocardial injury in patients with intracerebral hemorrhage. Am J Emerg Med. 2012;30:545–552. doi: 10.1016/j. ajem.2011.02.007 [MEDLINE]
Repolarization abnormalities in patients with subarachnoid and intracerebral hemorrhage: predisposing factors and association with outcome. Anesth Analg. 2013;116:190–197. doi: 10.1213/ ANE.0b013e318270034a [MEDLINE]
Elevated troponin levels are associated with higher mortality following intracerebral hemorrhage. Neurology. 2006;66:1330–1334. doi: 10.1212/01.wnl.0000210523.22944.9b [MEDLINE]
Relation of cardiac troponin I levels with in-hospital mortality in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Am J Cardiol. 2008;102:632–634. doi: 10.1016/j. amjcard.2008.04.036 [MEDLINE]
Treatment
General
Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials. Stroke. 2012;43:2149–2156. doi: 10.1161/STROKEAHA.112.655894 [MEDLINE]
INTERACT2 Trial. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013 Jun 20;368(25):2355-65. doi: 10.1056/NEJMoa1214609. Epub 2013 May 29 [MEDLINE]
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069. Epub 2015 May 28 [MEDLINE]
Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage. Ann Neurol. 2015 Jul;78(1):54-62. doi: 10.1002/ana.24416. Epub 2015 May 14 [MEDLINE]
Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet. 2018 May 26;391(10135):2107-2115. doi: 10.1016/S0140-6736(18)31033-X [MEDLINE]
Respiratory Management
Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA. 2022 May 4. doi: 10.1001/jama.2022.4798 [MEDLINE]
Prognosis
The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001 Apr;32(4):891-7 [MEDLINE]
