eMedicine Specialties > Neurology > Neurological Emergencies
Intracranial Hemorrhage: Treatment & Medication
Updated: Apr 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Medical therapy of intracranial hemorrhage is principally focused on adjunctive measures to minimize injury and to stabilize individuals in the perioperative phase. Recent clinical trial data suggests that treatment with recombinant factor VIIa (rFVIIa) within 4 hours after the onset of intracerebral hemorrhage limits the growth of the hematoma, reduces mortality, and improves functional outcomes at 90 days.8 However, further study of this medication in a broader cohort did not result in improved clinical outcomes. This intervention may also result in a small increase in the frequency of thromboembolic adverse events. The early use of rFVIIa in patients with head injury without systemic coagulopathy may reduce the occurrence of enlargement of contusions, the requirement of further operation, and adverse outcome.9
- Perform endotracheal intubation for patients with decreased level of consciousness and poor airway protection.
- Cautiously lower blood pressure to a mean arterial pressure (MAP) less than 130 mm Hg, but avoid excessive hypotension.
- Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan.
- Intubate and hyperventilate if intracranial pressure is increased; initiate administration of mannitol for further control.
- Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion without exacerbating brain edema.
- Avoid hyperthermia.
- Correct any identifiable coagulopathy with fresh frozen plasma, vitamin K, protamine, or platelet transfusions.
- Initiate fosphenytoin or other anticonvulsant definitely for seizure activity or lobar hemorrhage, and optionally in other patients.
- Facilitate transfer to the operating room or ICU.
Surgical Care
- Consider nonsurgical management for patients with minimal neurological deficits or with intracerebral hemorrhage volumes less than 10 mL.
- Consider surgery for patients with cerebellar hemorrhage greater than 3 cm, for patients with intracerebral hemorrhage associated with a structural vascular lesion, and for young patients with lobar hemorrhage. The common hypertensive hemorrhages in the basal ganglia have not been shown clearly to benefit from surgery, although case series with favorable outcomes after stereotactic needle evacuation or endoscopic drainage have been reported. In the past, standard craniotomy with evacuation of the hematoma did not appear to improve outcomes.
- Other surgical considerations include the following:
- Clinical course and timing
- Patient's age and comorbid conditions
- Etiology
- Location of the hematoma
- Mass effect and drainage patterns
- Surgical approaches include the following:
- Craniotomy and clot evacuation under direct visual guidance
- Stereotactic aspiration with thrombolytic agents
- Endoscopic evacuation
Consultations
- Neurosurgeon
- Neurologist
- Interventional neuroradiologist
- Rehabilitation specialist
Diet
- Employ aspiration precautions and obtain evaluation of patient's swallowing.
- Initiate enteral feedings as soon as possible. The patient may require placement of a nasogastric tube or percutaneous device.
Activity
- Maintain bedrest during the first 24 hours.
- Follow with progressive increase in activity.
- Avoid strenuous exertion.
Medication
Antihypertensive agents reduce blood pressure to prevent exacerbation of intracerebral hemorrhage. Osmotic diuretics, such as mannitol, may be used to decrease intracranial pressure. As hyperthermia may exacerbate neurological injury, acetaminophen may be given to reduce fever and to relieve headache. Anticonvulsants are used routinely to avoid seizures that may be induced by cortical damage. Vitamin K and protamine may be used to restore normal coagulation parameters. Antacids are used to prevent gastric ulcers associated with intracerebral hemorrhage.
Antihypertensive agents
These agents reduce blood pressure to prevent exacerbation of intracerebral hemorrhage.
Labetalol (Normodyne, Trandate)
Antagonizes adrenergic receptors, thereby reducing blood pressure.
Adult
20 mg IV, followed by 40 or 80 mg IV q10min; titrate until targeted blood pressure achieved or maximum of 300 mg administered
Pediatric
Not established
Concomitant use of TCAs may cause tremor; inhibits effects of some bronchodilators; cimetidine increases bioavailability; concomitant halothane anesthesia or nitroglycerin may cause hypotension
Documented hypersensitivity; prolonged hypotension; bronchial asthma; cardiac failure; second- or third-degree heart block; severe bradycardia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Individuals with hepatic dysfunction may have impaired clearance of labetalol
Nicardipine (Cardene, Cardene SR)
Calcium channel blocker. Potent rapid onset of action, ease of titration, and lack of toxic metabolites. Effective but limited reported experience in hypertensive encephalopathy.
Adult
Loading dose: 5-15 mg/h IV
Maintenance dose: 3-5 mg/h IV
Pediatric
Not established
Fentanyl and alcohol may increase hypotensive effects; calcium channel blocker may increase cyclosporine levels; H2 blockers (cimetidine), erythromycin, nafcillin, and azole antifungals may increase toxicity (avoid combination or monitor closely); carbamazepine may reduce bioavailability (avoid this combination); rifampin may decrease levels (monitor and adjust dose of calcium channel blocker)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal/hepatic impairment; may cause lower extremity edema; allergic hepatitis have occurred but is rare
Osmotic diuretics
Osmotic diuretics reverse pressure gradient across the blood-brain barrier, reducing intracranial pressure.
Mannitol (Osmitrol, Resectisol)
Reduces cerebral edema with help of osmotic forces and decreases blood viscosity, resulting in reflex vasoconstriction and lowering of intracranial pressure.
Adult
0.75-1 g/kg IV, followed by 0.25-0.5 g/kg IV q3-5h to maintain serum hyperosmolarity (approximately 320 mOsm/L)
Pediatric
Not established; dose is dependent on weight, clinical condition, and laboratory results
May decrease serum lithium levels
Documented hypersensitivity; anuria; severe pulmonary congestion; progressive renal damage; severe dehydration; active intracranial bleeding; progressive heart failure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Carefully evaluate cardiovascular status before rapid administration of mannitol, since sudden increase in extracellular fluid may lead to fulminating CHF; avoid pseudoagglutination, when blood given simultaneously, add at least 20 mEq of sodium chloride to each liter of mannitol solution; do not give electrolyte-free mannitol solutions with blood
Antipyretics, analgesics
These agents reduce fever and relieve pain.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
Reduces fever, maintains normothermia, and reduces headache.
Adult
650 mg PO/PR q4-6h; not to exceed 4 g/d
Pediatric
Infants: 10-15 mg/kg PO/PR q4-6h
Children: 65 mg/y up to 650 mg PO/PR q4-6h; not to exceed 15 mg/kg q4h
None reported
Documented hypersensitivity; known G-6-P deficiency; hepatic dysfunction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Anticonvulsants
These agents reduce the frequency of seizures and provide seizure prophylaxis.
Fosphenytoin (Cerebyx)
Diphosphate ester salt of phenytoin that acts as water-soluble prodrug of phenytoin. Following administration, plasma esterases convert fosphenytoin to phosphate, formaldehyde, and phenytoin. Phenytoin in turn stabilizes neuronal membranes and decreases seizure activity.
To avoid need to perform molecular weight-based adjustments when converting between fosphenytoin and phenytoin sodium doses, express dose as phenytoin sodium equivalents (PE). Although can be administered IV and IM, IV route is route of choice and should be used in emergency situations.
Concomitant administration of IV benzodiazepine usually necessary to control status epilepticus. Full antiepileptic effect of phenytoin, whether given as fosphenytoin or parenteral phenytoin, not immediate.
Adult
15-20 mg/kg IV loading dose, followed by 300 mg IV q24h
Pediatric
Not established; suggested weight-adjusted dose is as in adults
Amiodarone, benzodiazepines, chloramphenicol, cimetidine, disulfiram, ethanol (acute ingestion), omeprazole, phenacemide, phenylbutazone, succinimides, fluconazole, isoniazid, metronidazole, miconazole, sulfonamides, trimethoprim, and valproic acid may increase toxicity
Barbiturates, carbamazepine, theophylline, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, and sucralfate may decrease effects
May decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, methadone, metyrapone, mexiletine, oral contraceptives, quinidine, theophylline, valproic acid
Documented hypersensitivity; sinus bradycardia; sinoatrial and third-degree AV block; Adams-Stokes syndrome
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Avoid rapid administration to reduce risks of hypotension and cardiac arrhythmias; monitor for blood dyscrasias with serial blood tests; discontinue use if skin rash appears and do not resume use if rash is exfoliative, bullous, or purpuric; use caution in patients with acute intermittent porphyria, diabetes, or hepatic dysfunction
Antidotes
This agent reverses some coagulopathies or bleeding diatheses.
Phytonadione; vitamin K (Konakion, Mephyton, AquaMEPHYTON)
Promotes hepatic synthesis of clotting factors that inhibit warfarin effects.
Adult
2.5-10 mg SC/IM, repeat q6-8h until PT normalized
Pediatric
Not established; suggested dose is as in adults
Antagonizes effects of warfarin sodium and dicumarol
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Ineffective in hereditary hypoprothrombinemia
Protamine sulfate
Forms a salt with heparin and neutralizes its effects.
Adult
Dosage adjusted to time interval since discontinuation of IV heparin
Immediately: 1-1.5 mg/100 U heparin
30-60 min: 0.5-0.75 mg/100 U heparin
>60 min: 0.25-0.375 mg/100 U heparin
If SC heparin used, give 1-1.5 mg/100 U heparin; not to exceed 50 mg IV over 10 min
Pediatric
Not established; suggested dose is as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Heparin rebound associated with anticoagulation and bleeding may occur
Antacids
These agents provide prophylaxis of gastric ulcers.
Famotidine (Pepcid)
Minimizes development of gastric ulcers.
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen concentration.
Adult
20 mg IV/PO bid
Pediatric
Not established; suggested dose is as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
If changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
More on Intracranial Hemorrhage |
| Overview: Intracranial Hemorrhage |
| Differential Diagnoses & Workup: Intracranial Hemorrhage |
 Treatment & Medication: Intracranial Hemorrhage |
| Follow-up: Intracranial Hemorrhage |
| Multimedia: Intracranial Hemorrhage |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
intracranial hemorrhage, intracerebral hemorrhage, intraparenchymal hemorrhage, intracranial hematoma, intracerebral hematoma, intraparenchymal hematoma, epidural hematoma, subdural hematoma, subarachnoid hemorrhage, intraventricular hemorrhage, intracranial pressure
