Intracranial Hemorrhage Follow-up

Updated: Oct 13, 2017
  • Author: David S Liebeskind, MD, FAAN, FAHA, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Follow-up

Further Outpatient Care

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  • 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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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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Inpatient & Outpatient Medications

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  • 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

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  • 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 [17, 18]
  • 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

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  • 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

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  • 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. [19]
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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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