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=== Early assessment ===
=== Early assessment ===
Intracerebral hemorrhage (ICH) is a medical emergency. Rapid diagnosis and management is crucial because early deterioration is common in the first few hours after ICH onset.<ref name="pmid18007267">{{cite journal|author=Moon JS, Janjua N, Ahmed S, Kirmani JF, Harris-Lane P, Jacob M et al.|title=Prehospital neurologic deterioration in patients with intracerebral hemorrhage.|journal=Crit Care Med|year=2008|volume=36|issue=1|pages=172-5|pmid=18007267|doi=10.1097/01.CCM.0000297876.62464.6B|pmc=|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18007267}}</ref>
Intracerebral hemorrhage (ICH) is a medical emergency. Rapid diagnosis and management is crucial because early deterioration is common in the first few hours after ICH onset.<ref name="pmid18007267">{{cite journal|author=Moon JS, Janjua N, Ahmed S, Kirmani JF, Harris-Lane P, Jacob M et al.|title=Prehospital neurologic deterioration in patients with intracerebral hemorrhage.|journal=Crit Care Med|year=2008|volume=36|issue=1|pages=172-5|pmid=18007267|doi=10.1097/01.CCM.0000297876.62464.6B|pmc=|url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18007267}}</ref>
===Management===
Spontaneous intracerebral hemorrhage (ICH) remains a significant cause of morbidity and mortality throughout the world. However, the excellent medical care has a potent, direct impact on spontaneous intracerebral hemorrhage (ICH) morbidity and mortality.<ref name="pmid 10.1136/jnnp.2005.077164.">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid= 10.1136/jnnp.2005.077164. | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }}</ref> The non-surgical management of intracerebral hemorrhage is mainly directed to [[hemostasis]]/[[coagulopathy]] management, [[Blood pressure|blood pressure (BP)]] management, [[glucose]]/temperature/[[seizure]] management, and other medical complications and procedures, including management of [[Intracranial pressure|intracranial pressure (ICP)]] and [[intraventricular hemorrhage]].<ref name="ASA/AHA-ICH-Guid" />


'''For AHA/ASA guidelines for the management of ICH, please [[AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage|click here]]'''
===Surgery===
The indications for surgery in patients with Intracerebral hemorrhage vary with the site of the bleed. Open [[craniotomy]] is the most widely studied surgical techniques in patients with [[supratentorial]] ICH.<ref name="Mendelow" /><ref name="Gregson-AD" /> Recently, several studies have shown minimally invasive aspiration associated with better outcomes with less invasive approaches compared to standard craniotomies.<ref name="Fung" /><ref name="Wang">Wang WZ, Jiang B, Liu HM, Li D, Lu CZ, Zhao YD, Sander JW. Minimally invasive craniopuncture therapy vs. conservative treat- ment for spontaneous intracerebral hemorrhage: results from a ran- domized clinical trial in China. Int J Stroke. 2009;4:11–16. doi: 10.1111/j.1747-4949.2009.00239.x.</ref><ref name="Mould">Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF; MISTIE Investigators. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intrace- rebral hemorrhage evacuation decreases perihematomal edema. Stroke. 2013;44:627–634. doi: 10.1161/STROKEAHA.111.000411.</ref>
===Primary prevention===
Primary prevention of intracerebral hemorrhage is mainly aimed at treatment and modifcation of risk factors which are directly associated with increased occurrence of intracerebral hemorrhage.<ref name="ASA/AHA-Primary-Prevention-Guid" />
===Secondary prevention===
Effective measures for the secondary prevention of intracerebral hemorrhage include life style modification, treatment of modifiable risk factors such as blood pressure control and anticoagulation medication avoidance, and enforcing the measures to prevent the complications.<ref name="ASA/AHA-ICH-Guid2" /><ref name="ASA/AHA-Primary-Prevention-Guid" /><ref name="DOACs" /><ref name="pmid21309657" /><ref name="Eckman" /><ref name="pmid20539816" /><ref name="pmid23983842" />


==References==
==References==

Revision as of 13:47, 4 December 2016

Intracerebral hemorrhage Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Stroke from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Emergency Diagnosis and Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

CT

MRI

Other Imaging Findings

Treatment

Early Assessment

Management

Surgery

Primary Prevention

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AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015)

Management of ICH

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Classification

Intracerebral hemorrhage is bleeding within the brain itself. This category includes:[1][2][3]

 
 
 
 
 
 
 
 
Intracerebral bleeding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intraparenchymal hemorrhage
 
 
 
 
Intraventricular hemorrhage
 
 
 
 
Cerebral microbleeds


Pathophysiology

Intracerebral hemorrhage (ICH) is bleeding directly into the brain tissue and usually results from rupture of small penetrating arteries in the brain. Degenerative changes in the vessel wall may be associated with advancing age, chronic HTN, diabetes, and other vascular risk factor and It usually occurs at or near the bifurcation of affected arterioles.[4][5] The exact cause of brain damage following intracerebral hemorrhage is unknown. It is thought that ICH may result in brain injury by decreasing blood flow into the area surrounding the clot and causing neuronal ischemia or by overexertion of matrix metalloproteinases (MMPs), which may result in the breakdown of the blood brain barrier and edema.[6][7]

Causes

The two major causes of intracerebral hemorrhage include long-standing hypertension and cerebral amyloid angiopathy.[8][9][10][11][12][13] Other causes of intracerebral hemorrhage include vascular malformations (arteriovenous malformations (AVMs)) aneurysms, drugs (cocaineamphetamines), and vasculitis.[8][9]

Differential diagnosis

Differential diagnosis of intracerebral hemorrhage may include ischemic stroke, SAH, TIA, acute hypertensive crisis, sentinel headache, sinusitis, hypoglycemia, cerebral venous thrombosis, spontaneous intracranial hypotension, and reversible cerebral vasoconstriction syndrome.[14][15][16][17][18] It is clinically difficult to distinguish ICH or subarchnoid hemorrhage (SAH) from an ischemic stroke. However, the symptoms like headache, nausea, vomiting, and depressed level of consciousness should raise the suspicion for a hemorrhagic event compared to ischemic stroke.[19][20]

Epidemiology

The overall incidence of intracerebral hemorrhage (ICH) ranges from 12 to 31 per 100,000 population.[21] The incidence of intracerebral hemorrhage gets doubled every 10 years after age 35 every, but the prevalence and incidence does not vary by gender.[22][23] The incidence of intracerebral hemorrhage is the highest in Asians.[24]

Risk factors

Common risk factors in the development of intracerebral hemorrhage (ICH) include hypertension, anticoagulation medication(warfarin), acquired or congenital coagulation factor disorder (such as vitamin K deficiency, liver disease, disseminated Intravascular Coagulation (DIC), and hemophilias), platelet abnormalities, embolic strokes, and Sickle Cell Anemia.[25][26][27][28]

Natural history, Complications, and Prognosis

Intracerebral hemorrhage is a medical emergency requiring urgent diagnosis and treatment. If left untreated, it may result in irreversible brain tissue damage. causing permanent neurological deficit and death.[29][30] The most common complications following intracerebral hemorrhage (ICH) include hematoma expansion, venous thromboembolism (VTE), pneumonia, apiration, respiratory failure/distress pulmonary embolism, sepsis, neurogenic pulmonary edema, acute respiratory distress syndrome, and acute kidney injury.[31][32][33]

Despite aggressive and newer management strategies, the prognosis of patients with intracerebral hemorrhage is very poor. The main powerful predictor of 30-day mortality and morbidity in patients with spontaneous intracerebral hemorrhage is a volume of hemorrhage in combination with the initial Glasgow Coma Scale score (GCS).[34][35]

Diagnosis

Emergency diagnosis and assessment

Intracerebral hemorrhage is a medical emergency, characterized by high morbidity and mortality, which should be promptly diagnosed and aggressively managed. Hematoma expansion and early deterioration are common within the first few hours after onset. CT and magnetic resonance imaging (MRI) are both reasonable for initial evaluation.[36]

History and Symptoms

It is critical to obtain a detailed and focused history in patient with intracerebral hemorrhage. History of gradual onset of symptoms,Vomitinghypertensionlipid disorders, smoking, antiplatlete/anticoagulation medication, or illicit drug use, dementialiver, and chronic kidney disease may suggest intracerebral hemorrhage as one of the initial differential diagnosis..[1][2][3][4][5][6]

Physical examination

Physical examination of patients with Intracerebral hemorrhage usually varies based on the location of the bleeding.[37] Physical examination of patients with intracerebral hemorrhage should include vital signs check and assessment of level of consciousness (GCS) and the severity of the neurological defect (NIHSS).[38][39]

Laboratory findings

Routine laboratory studies in patient with intracerebral hemorrhage should include complete blood count (CBC) with platelets,electrolytesrenal function, coagulation studies (prothrombin time (PT)partial thromboplastin time (PTT), and INR), toxicology screen, blood glucose level, and pregnancy test in women of childbearing age.[1][2][3][4][5][6]

Electrocardiogram

Following intracerebral hemorrhage and secondary to catecholamines release following posterior hypothalamus hypoperfusion, the EKG changes may show changes which is a reflection of left ventricular ischemia. Additionally, brainstem compression may result in ventricular arrhythmias.[40][41]

CT

CT is very sensitive for identifying acute hemorrhage and is considered the gold standard.[42][43]

MRI

MRI is better than CT for detection of acute and chronic hemorrhage. Therefore it should be the preferred test for accurate diagnosis of patients with suspected intracerebral hemorrhage.[44]

Other imaging findings

Other imaging findings in diagnosis of intracerebral hemorrhage may include CT angiography (CTA), CT venography (CTV), MR angiography (MRA), MR venography (MRV), and ctheter angiogram.[45][46]

Treatment

Early assessment

Intracerebral hemorrhage (ICH) is a medical emergency. Rapid diagnosis and management is crucial because early deterioration is common in the first few hours after ICH onset.[47]

Management

Spontaneous intracerebral hemorrhage (ICH) remains a significant cause of morbidity and mortality throughout the world. However, the excellent medical care has a potent, direct impact on spontaneous intracerebral hemorrhage (ICH) morbidity and mortality.[48] The non-surgical management of intracerebral hemorrhage is mainly directed to hemostasis/coagulopathy management, blood pressure (BP) management, glucose/temperature/seizure management, and other medical complications and procedures, including management of intracranial pressure (ICP) and intraventricular hemorrhage.[49]

For AHA/ASA guidelines for the management of ICH, please click here

Surgery

The indications for surgery in patients with Intracerebral hemorrhage vary with the site of the bleed. Open craniotomy is the most widely studied surgical techniques in patients with supratentorial ICH.[50][51] Recently, several studies have shown minimally invasive aspiration associated with better outcomes with less invasive approaches compared to standard craniotomies.[52][53][54]

Primary prevention

Primary prevention of intracerebral hemorrhage is mainly aimed at treatment and modifcation of risk factors which are directly associated with increased occurrence of intracerebral hemorrhage.[55]

Secondary prevention

Effective measures for the secondary prevention of intracerebral hemorrhage include life style modification, treatment of modifiable risk factors such as blood pressure control and anticoagulation medication avoidance, and enforcing the measures to prevent the complications.[56][55][57][58][59][60][61]

References

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  43. Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, Hill MD, Patronas N, Latour L, Warach S. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369:293–298. doi: 10.1016/S0140-6736(07)60151-2.
  44. Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM; et al. (2007). "Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison". Lancet. 369 (9558): 293–8. doi:10.1016/S0140-6736(07)60151-2. PMC 1859855. PMID 17258669.
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  47. Moon JS, Janjua N, Ahmed S, Kirmani JF, Harris-Lane P, Jacob M; et al. (2008). "Prehospital neurologic deterioration in patients with intracerebral hemorrhage". Crit Care Med. 36 (1): 172–5. doi:10.1097/01.CCM.0000297876.62464.6B. PMID 18007267.
  48. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID 10.1136/jnnp.2005.077164.  10.1136/jnnp.2005.077164. Check |pmid= value (help).
  49. Wang WZ, Jiang B, Liu HM, Li D, Lu CZ, Zhao YD, Sander JW. Minimally invasive craniopuncture therapy vs. conservative treat- ment for spontaneous intracerebral hemorrhage: results from a ran- domized clinical trial in China. Int J Stroke. 2009;4:11–16. doi: 10.1111/j.1747-4949.2009.00239.x.
  50. Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF; MISTIE Investigators. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intrace- rebral hemorrhage evacuation decreases perihematomal edema. Stroke. 2013;44:627–634. doi: 10.1161/STROKEAHA.111.000411.
  51. 55.0 55.1


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