eMedicine Specialties > Neurology > Neurological Emergencies

Intracranial Hemorrhage: Follow-up

Author: David S Liebeskind, MD, Associate Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California at Los Angeles; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center
Contributor Information and Disclosures

Updated: Apr 27, 2009

Follow-up

Further Inpatient Care

  • Initial management of intracerebral hemorrhage generally is conducted in the ICU. Subsequent care generally includes the following:
    • Serial neurologic examinations
    • Treatment of elevated intracranial pressure
    • Placement of ventricular catheter should hydrocephalus develop
    • Avoidance of hypotension or hypertension (MAP = 70-130 mm Hg)
    • Use of isotonic solutions, such as normal saline, to minimize cerebral edema
    • Treatment with 3 X isotonic saline should hyponatremia due to cerebral salt wasting occur
    • Avoidance of hyperthermia
    • Treatment or prophylaxis of seizures
    • Treatment of urinary tract infections
    • Prevention of venous thrombosis with intermittent compression stockings plus or minus low-dose subcutaneous unfractionated or low molecular weight heparin
    • Prophylaxis for gastric ulcers
    • Physical, occupational, and speech therapy
    • Psychological support with cautious use of sedatives, if necessary
    • Repeat CT scan in case of clinical deterioration

Further Outpatient Care

  • After hospital discharge, continued physical, occupational, and speech therapy may be required.
  • Administer medications to control hypertension and to prevent complications such as seizures, urinary tract infections, or venous thromboses.

Inpatient & Outpatient Medications

  • Antihypertensives for modification of blood pressure
  • Mannitol or other osmotic diuretics for elevated intracranial pressure
  • Acetaminophen for fever and headache relief
  • Fosphenytoin or other anticonvulsants for posttraumatic seizures
  • Famotidine or other antacids for gastric ulcer prophylaxis
  • Anticholinergics for bladder complications
  • Baclofen, diazepam, or tizanidine for spasticity
  • Amitriptyline, carbamazepine, or gabapentin for neuropathic pain

Transfer

Following prehospital and emergent stabilization, patients with intracerebral hemorrhage should be transferred to a medical facility with neurosurgical expertise.

Deterrence/Prevention

  • Early detection and aggressive treatment of hypertension
  • Cautious management of anticoagulation and other antithrombotic medications
  • Careful selection of subjects suitable for thrombolysis
  • Consideration of cerebral amyloid angiopathy as a significant risk factor for intracerebral hemorrhage10,11
  • Public education campaigns emphasizing the dangers of heavy alcohol intake and sympathomimetic use
  • Public education regarding traumatic brain injury, including appropriate use of safety equipment, precautions, and measures that may reduce the incidence of head injury
  • Prevention and management of preterm labor that may reduce intraventricular hemorrhage due to germinal matrix hemorrhage

Complications

  • Neurological deficits or death
  • Seizures
  • Hydrocephalus
  • Spasticity
  • Urinary complications
  • Aspiration pneumonia
  • Neuropathic pain
  • Deep venous thrombosis
  • Pulmonary emboli
  • Cerebral herniation

Prognosis

  • Early reduction in the level of consciousness carries an ominous prognosis.
  • The size and location of intracerebral hemorrhage provide useful prognostic information.
    • Larger hematomas have a worse outcome.
    • Lobar hemorrhage has a better outcome than deep hemorrhage.
    • Significant volume of intraventricular blood is a poor prognostic indicator.
  • The presence of hydrocephalus is associated with a poor outcome.
  • Good outcome in medium to large intracerebral hemorrhage can be predicted on admission by neurologic severity, intracerebral hemorrhage location, and fibrinogen levels.12

Patient Education

  • Educate patients regarding the following:
    • Treatment of hypertension
    • Warning signs and symptoms of stroke as well as preventive measures
    • Traumatic brain injury
    • Adverse effects of alcohol and sympathomimetic substances

Miscellaneous

Medicolegal Pitfalls

  • Delayed transfer and triage
  • Failure to consider clinical diagnosis of intracerebral hemorrhage
  • Failure to obtain emergent CT scan
  • Failure to perform serial neurologic assessments and detect delayed deterioration

Special Concerns

  • Consider the relative risks and benefits of anticoagulation for individuals with intracerebral hemorrhage at high risk of embolic phenomena, such as mechanical cardiac valves. Anticoagulation usually may be restarted within 2-3 weeks after intracerebral hemorrhage.
  • Diagnosis and management of pregnant women with intracerebral hemorrhage require careful selection of neuroradiologic studies and medications, with due consideration of teratogenic effects.
 


More on Intracranial Hemorrhage

Overview: Intracranial Hemorrhage
Differential Diagnoses & Workup: Intracranial Hemorrhage
Treatment & Medication: Intracranial Hemorrhage
Follow-up: Intracranial Hemorrhage
Multimedia: Intracranial Hemorrhage
References
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References

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Further Reading

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Keywords

intracranial hemorrhage, intracerebral hemorrhage, intraparenchymal hemorrhage, intracranial hematoma, intracerebral hematoma, intraparenchymal hematoma, epidural hematoma, subdural hematoma, subarachnoid hemorrhage, intraventricular hemorrhage, intracranial pressure

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Contributor Information and Disclosures

Author

David S Liebeskind, MD, Associate Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California at Los Angeles; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center
David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey L Saver, MD, Director, Stroke Center, Professor, Department of Neurology, University of California at Los Angeles Medical Center
Jeffrey L Saver, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Neurological Association, and National Stroke Association
Disclosure: Boehringer-Ingelheim - Secondary Prevention Consulting fee Consulting; Talacris Consulting fee Consulting; ImaRx Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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