Saturday, May 05, 2007
intra cerebral hemorrhage ICH
Study Highlights
* Classic symptoms of ICH include the sudden onset of a focal neurologic deficit, which progresses over minutes to hours. Vomiting is more common with ICH than with ischemic stroke or subarachnoid hemorrhage.
* Either CT or MRI may be used for initial neuroimaging of patients suspected of having ICH, but MRI may be more difficult to perform because of impaired consciousness, vomiting, or agitation.
* Recombinant factor VIIa has demonstrated promise in early trials in terms of reducing hematoma size, mortality, and 90-day disability among patients with ICH, but further testing is necessary to assess this therapy.
* If systolic blood pressure exceeds 200 mm Hg in a patient with ICH, continuous intravenous antihypertensive therapy should be considered. A target blood pressure of 160/90 mm Hg is reasonable.
* Treatment of elevated ICP should begin with conservative measures, such as elevation of the head of the bed, analgesia, and sedation. Further steps can include osmotic therapy with mannitol or hyperventilation, which can be associated with hypovolemia and decreased cerebral blood flow, respectively.
* Serum glucose levels should be lowered to at least less than 300 mg/dL after ICH.
* Patients with hemiparesis or hemiplegia following ICH should receive prophylaxis with intermittent pneumatic compression stockings. These patients may receive low-molecular-weight heparin after 3 to 4 days following cessation of bleeding.
* Patients with ICH who develop acute proximal venous thrombosis should be considered for acute placement of a vena cava filter.
* Patients who develop ICH while receiving warfarin should receive intravenous vitamin K. Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII can reduce patients' international normalized ratio very rapidly and with less fluid infusion vs fresh frozen plasma, but these newer therapies are associated with a higher risk for thromboembolism.
* The decision of whether to reinitiate warfarin therapy following ICH should be individualized based on the patient's risk for repeat ICH and thromboembolism. Warfarin may be restarted 7 to 10 days following ICH among patients at high risk for thromboembolism.
* Surgical intervention should be considered for patients with cerebellar hemorrhage of 3 cm or greater who are deteriorating neurologically. Patients with brainstem compression or ventricular obstruction resulting from hemorrhage may also be considered for surgical intervention. Patients with lobar clots within 1 cm of the surface may be considered for evacuation of ICH with craniotomy.
Pearls for Practice
* ICH accounts for up to 15% of first-time strokes and associated mortality rates can exceed 50%. Half of patients with ICH who die do so in the first 2 days following hemorrhage.
* The current guidelines for patients with ICH recommend initial conservative measures to reduce ICP and prophylaxis against deep venous thrombosis for all ICH patients with limited mobility. Warfarin therapy may be restarted among patients with ICH who are at high risk for thromboembolism.
* Classic symptoms of ICH include the sudden onset of a focal neurologic deficit, which progresses over minutes to hours. Vomiting is more common with ICH than with ischemic stroke or subarachnoid hemorrhage.
* Either CT or MRI may be used for initial neuroimaging of patients suspected of having ICH, but MRI may be more difficult to perform because of impaired consciousness, vomiting, or agitation.
* Recombinant factor VIIa has demonstrated promise in early trials in terms of reducing hematoma size, mortality, and 90-day disability among patients with ICH, but further testing is necessary to assess this therapy.
* If systolic blood pressure exceeds 200 mm Hg in a patient with ICH, continuous intravenous antihypertensive therapy should be considered. A target blood pressure of 160/90 mm Hg is reasonable.
* Treatment of elevated ICP should begin with conservative measures, such as elevation of the head of the bed, analgesia, and sedation. Further steps can include osmotic therapy with mannitol or hyperventilation, which can be associated with hypovolemia and decreased cerebral blood flow, respectively.
* Serum glucose levels should be lowered to at least less than 300 mg/dL after ICH.
* Patients with hemiparesis or hemiplegia following ICH should receive prophylaxis with intermittent pneumatic compression stockings. These patients may receive low-molecular-weight heparin after 3 to 4 days following cessation of bleeding.
* Patients with ICH who develop acute proximal venous thrombosis should be considered for acute placement of a vena cava filter.
* Patients who develop ICH while receiving warfarin should receive intravenous vitamin K. Prothrombin complex concentrate, factor IX complex concentrate, and recombinant activated factor VII can reduce patients' international normalized ratio very rapidly and with less fluid infusion vs fresh frozen plasma, but these newer therapies are associated with a higher risk for thromboembolism.
* The decision of whether to reinitiate warfarin therapy following ICH should be individualized based on the patient's risk for repeat ICH and thromboembolism. Warfarin may be restarted 7 to 10 days following ICH among patients at high risk for thromboembolism.
* Surgical intervention should be considered for patients with cerebellar hemorrhage of 3 cm or greater who are deteriorating neurologically. Patients with brainstem compression or ventricular obstruction resulting from hemorrhage may also be considered for surgical intervention. Patients with lobar clots within 1 cm of the surface may be considered for evacuation of ICH with craniotomy.
Pearls for Practice
* ICH accounts for up to 15% of first-time strokes and associated mortality rates can exceed 50%. Half of patients with ICH who die do so in the first 2 days following hemorrhage.
* The current guidelines for patients with ICH recommend initial conservative measures to reduce ICP and prophylaxis against deep venous thrombosis for all ICH patients with limited mobility. Warfarin therapy may be restarted among patients with ICH who are at high risk for thromboembolism.
# posted by roodbont @ 12:40 PM 
