Template:ICH Treatment

Elevating head of bed

• 30 degree elevation will help decrease ICP by increasing venous outflow

Seizure Prophylaxis and Treatment

• Prophylactic antiepileptics not recommended
• Continuous EEG monitoring probably indicated in ICH patients with depressed mental status that is out of proportion fo degree of brain injury
• Antiepileptics indicated for clinical seizures or seizures on EEG in patients with altered mental status

Blood Pressure

• Rapid SBP lowering <140 has been advocated with early research showing improved functional outcome, but more recent work has found no difference between SBP <140 and <180
• SBP >200 or MAP >150
  • Consider aggressive reduction w/ continuous IV infusion
• SBP >180 or MAP >130 and evidence or suspicion of elevated ICP
  • Consider reducing BP using intermittent or continuous IV meds to keep CPP >60-80
• SBP >180 or MAP >130 and NO evidence or suspicion of elevated ICP
  • Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)

• Nicardipine in ICH: Start at 5mg/hr, increase 2.5mg q5min until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
• Labetalol in ICH: 20mg bolus over 1-2 minutes, repeat q3-5 mins until target blood pressure is achieved and then start an infusion of 1-8mg/min.

Reverse coagulopathy

• See anticoagulant reversal for life-threatening bleeds if on a known anticoagulant (e.g. heparin, coumadin, rivaroxaban)
• Tranexamic acid 1g (if within 3 hours of event), followed by an additional 1g infused over 8 hours

Antiplatelet Reversal

Includes aspirin, prasugrel, clopidogrel

• Consider desmopressin (0.3mcg/kg)
• Platelet transfusion
  • No known thrombocytopenia: increases mortality; do NOT give
  • Known or diagnosed thrombocytopenia: consider if platelets <50,000
    • Some hematologists and neurosurgeons recommend for <100,000, despite lack of evidence for improved outcomes