Intracranial Hemorrhage Follow-up

  • Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: Nov 17, 2011
 

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
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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.
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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
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Transfer

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

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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 hemorrhage[13, 14]
  • 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
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Complications

  • Neurological deficits or death
  • Seizures
  • Hydrocephalus
  • Spasticity
  • Urinary complications
  • Aspiration pneumonia
  • Neuropathic pain
  • Deep venous thrombosis
  • Pulmonary emboli
  • Cerebral herniation
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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.[15]
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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
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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, Los Angeles, David Geffen School of Medicine; 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.

Specialty Editor Board

Jeffrey L Saver, MD, FAHA, FAAN  Professor of Neurology, Director, UCLA Stroke Center, University of California, Los Angeles, David Geffen School of Medicine

Jeffrey L Saver, MD, FAHA, FAAN is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Neurological Association, and National Stroke Association

Disclosure: University of California The University of California Regents receive funds for consulting services on clinical trial design provided to Telecris, Ev3, and CoAxia. Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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: Nothing to disclose.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

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: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; 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; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

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Intracranial hemorrhage. CT scan of right frontal intracerebral hemorrhage complicating thrombolysis of an ischemic stroke.
Intracranial hemorrhage. Fluid-attenuated inversion-recovery, T2-weighted, and gradient echo MRI illustration of intracerebral hemorrhage associated with a right frontal arteriovenous malformation.
Intracranial hemorrhage. Fluid-attenuated inversion-recovery, T2-weighted, and gradient echo MRI depiction of left temporal intracranial hemorrhage due to sickle cell disease.
This MRI reveals petechial intracerebral hemorrhage (ICH) due to cerebral venous thrombosis.
This CT scan and MRI revealed midbrain intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) associated with a cavernous angioma.
This MRI reveals hemorrhagic transformation of an ischemic infarct.
Table 1. MRI Appearance of Intracerebral Hemorrhage
PhaseTimeHemoglobinT1T2
Hyperacute< 24 hoursOxyhemoglobin (intracellular)Iso or hypoHyper
Acute1-3 daysDeoxyhemoglobin (intracellular)Iso or hypoHypo
Early subacute>3 daysMethemoglobinHyperHypo
Late subacute>7 daysMethemoglobin (extracellular)HyperHyper
Chronic>14 daysHemosiderin (extracellular)Iso or hypoHypo
Table 2. Grading of Subependymal Hemorrhage
GradeHemorrhage Location
ISubependymal hemorrhage
IIIntraventricular hemorrhage without ventriculomegaly
IIIIntraventricular hemorrhage with ventriculomegaly
IVIntraventricular hemorrhage with parenchymal hemorrhage
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