Emergency Neurological Life Support: Intracerebral Hemorrhage

Andrews, Charles; Jauch, Edward C.; Hemphill, J. Claude; Smith, Wade S.; Weingart, Scott D.

doi:10.1007/s12028-015-0167-0

Cited by 46 publications

(15 citation statements)

References 73 publications

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“…According to the AHA/ASA guidelines [ 9 ] and the Emergency Neurological Life Support protocols [ 26 ], spontaneous intracranial hemorrhage is a medical emergency and should be managed accordingly. The initial management should focus on the following principles (Fig.…”

Section: Initial Evaluation and Clinical Stabilizationmentioning

confidence: 99%

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

et al. 2016

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Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1432-0) contains supplementary material, which is available to authorized users.

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Section: Initial Evaluation and Clinical Stabilizationmentioning

confidence: 99%

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

et al. 2016

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“…The Emergency Neurological Life Support (ENLS) Guidelines recommend that the following be completed within the first hour of presentation: complete blood count with platelet and prothrombin time (PT), partial thromboplastin time, and international normalization ratio (INR); brain imaging to determine size and location of hematoma; and Glasgow Coma Score (GCS) and ICH scores. 20 The utility of the National Institute of Health Stroke Scale (NIHSS) score may be diminished with depression in the level of consciousness that can accompany ICH. 4 Though it is not clear which severity score is optimal, the ICH and NIHSS scores are the most commonly used and provide a common language by which specialists can communicate.…”

Section: Emergency Department Managementmentioning

confidence: 99%

“…4 Airway and ventilation management, initiation of blood pressure control, and coagulopathy reversal, if needed, should all be initiated within the first hour. 20 Patients with ICH frequently require management in a critical care setting where close monitoring and quick intervention can be instituted. A 4-year single center retrospective study showed a fourfold increase in poor functional outcome and discharge NIHSS in patients who stayed longer than 5 hours in the ED.…”

Section: Emergency Department Managementmentioning

confidence: 99%

“…Dysregulation of the coagulation cascade from intrinsic or extrinsic influences can also lead to bleeding proclivity and result in spontaneous ICH; an initial workup for coagulopathy is crucial in all ICH patients presenting to the ED. 20,25 Intracerebral hemorrhage in the setting of coagulopathy carries a greater risk of hematoma expansion and a poorer prognosis. 30 Moreover, hematoma expansion and in-hospital mortality are significantly reduced when early INR-targeted reversal of coagulopathy (INR < 1.3 within 4 hours of hospital admission) is prioritized.…”

Section: Coagulopathymentioning

confidence: 99%

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Critical Care Management of Intracerebral Hemorrhage

Morawo

Gilmore

2016

Semin Neurol

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Spontaneous intracerebral hemorrhage (ICH), the most devastating and debilitating form of stroke, remains a major healthcare concern all over the world. Intracerebral hemorrhage is frequently managed in critical care settings where intensive monitoring and treatment are employed to prevent and address primary and secondary brain injury as well as other medical complications that may arise. Although there has been increasing data guiding the management of ICH in the past decade, prognosis remains dismal. In this article, the authors discuss the risk factors for ICH, the role of imaging, the major targets of neurocritical care management, the etiology and management of raised intracranial pressure, as well as prevention of and prompt response to the emergence of medical complications. They also discuss the effect of early withdrawal of life-sustaining therapy on prognosis. Finally, we outline several clinical trials that hold promise in improving our management of ICH in the near future.

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“…83 However, in clinical practice, concern for thrombotic complications of activated PCC may lead some to prefer rFVIIa or nonactivated PCC for reversing dabigatran until more prospective data are available. 84 Activated charcoal may be considered if ingestion of dabigatran was within 2 hours of hospital admission. Furthermore, intermittent hemodialysis effectively neutralizes 66% of the anticoagulant effect of dabigatran 80,85 ; however, its utility in ICH may be limited by the induced fluid shifts and rebound anticoagulant effect.…”

Section: Direct Thrombin Inhibitorsmentioning

confidence: 99%

Diagnosis and Management of Coagulopathy-Related Intracerebral Hemorrhage

VanDerWerf

Kumar

2016

Semin Neurol

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Coagulopathy, defined as impaired clot formation, is common in intensive care units (ICUs). Many physiological derangements lead to dysfunctional hemostasis in the ICU; most of these are acquired rather than congenital. Coagulopathies in the ICU are often related to systemic diseases, autoimmune dysfunction, acute infection, organ dysfunction, therapeutic medications, and/or other medical treatments. A significant complication of coagulopathy in the critically ill is major bleeding, defined as fatal hemorrhage, hemodynamic instability, transfusion requirement, or intracranial hematomas. Coagulopathy in the ICU often poses complex management dilemmas, especially when coagulopathy coexists with a thrombotic state. Coagulopathy associated with intracerebral hemorrhage (ICH) bears directly on neurologic prognosis and functional outcome. There is a paucity of high-quality evidence for the management of coagulopathies in neurocritical care; however, data derived from studies of patients with ICH may inform treatment decisions. This article focuses on acquired conditions such as pharmacological therapies, organ failure, and platelet dysfunction that are often associated with defective clot formation in the ICU that result in or exacerbate ICH.

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Emergency Neurological Life Support: Intracerebral Hemorrhage

Cited by 46 publications

References 73 publications

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Critical Care Management of Intracerebral Hemorrhage

Diagnosis and Management of Coagulopathy-Related Intracerebral Hemorrhage

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