Fine points in treating a spontaneous intracerebral hemorrhage

What should be done?

Common sites of an intracerebral hemorrhage.
Intracerebral hemorrhages commonly occur in the cerebral lobes, basal ganglia, thalamus, brain stem (predominantly the pons), and cerebellum

A spontaneous intracerebral hemorrhage is the most “untreatable” of the stroke/brain ischemia episodes. Occurs in about a million people worldwide every year. Primary spontaneous hemorrhage occurs in chronic hypertension or amyloid angiopathy usually from rupture of small vessels. If the bleeding occurs from an intracerebral aneurysm, cavernous hemangioma or tumour etc it is called a secondary hemorrhage. Alcohol and cocaine may be causative factors.

Initially intracerebral hemorrhage was thought to be monophasic, the clotting of the vessels and pressure of the hematoma was thought to limit the bleeding but recurrent bleeding does occur and worsens the prognosis. I am showing two scans from the NEJM showing progression of the hematoma.

The first CT scan (Panel A) was obtained one hour after the patient presented and was followed by neurologic deterioration and expansion of the hematoma visible on the CT scan obtained six hours after presentation (Panel B).

What should you do?

If the symptoms suggest a hematoma: severe headache, vomiting, an epileptiform fit, progressive loss of consciousness, a rising blood pressure do a CT scan without contrast at once and repeat it if the symptoms get worse or fresh neurological signs develop. Consider neurosurgical intervention i.e aspiration of the hematoma early if there is a cerebellar hemorrhage of 3 cm diameter and the GCS is less than 14, or a lobar hematoma of 30 ml volume in a young patient with a deteriorating condition or impending brain herniation specially if the bleed is into the ganglionic area. Consider intubation and using a mechanical ventilator and using IV mannitol and hyperventilation to reduce intracranial pressure.

CT Scans of a Basal Ganglionic Hematoma before (Panel A) and after (Panels B and C) Stereotactic Removal. NEJM.

In Panel A, the volume of the basal ganglionic hematoma was 60 ml preoperatively. Six infusions of urokinase (20,000 U each) were administered into the matrix of the hematoma every six to eight hours with concomitant aspiration. In Panel B, immediately after the aspiration of the hematoma, the hematoma is smaller and there is less displacement of surrounding tissue. Panel C shows the findings three days after the aspirations.

Should we lower the blood pressure?

The blood pressure should be lowered within one hour but to how much?Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage.

The second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) included patients with spontaneous intracerebral hemorrhage who had a systolic blood pressure of 150 to 220 mm Hg within 6 hours after symptom onset. The rate of death or disability among patients randomly assigned to intensive reduction in the systolic blood-pressure level, with a target systolic blood pressure of less than 140 mm Hg within 1 hour, was non significantly lower than the rate among those assigned to guideline-recommended treatment, with a target systolic blood pressure of less than 180 mm Hg, with the use of a variety of antihypertensive medications (absolute difference, 3.6 percentage points; P=0.06).5 The conclusion of the trial quoted below are: the treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg.

Further reading.

  1. Qureshi AI M.D. Yuko Y. Palesch PhD. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. The Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial. September 15, 2016
    N Engl J Med 2016; 375:1033-1043
  2. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013;368:2355-2365
  3. Anderson CS, Huang Y, Arima H, et al. Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke 2010;41:307-312
  4. Qureshi AI, Palesch YY, Martin R, et al. Interpretation and implementation of Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT II). J Vasc Interv Neurol 2014;7:34-40

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I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

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