Intracerebral hemorrhage (ICH), or bleeding directly into the brain parenchyma, occurs in 10-15% of stroke patients.
· The most common location is the subcortical white matter (lobar hemorrhage).
· Cerebellar hemorrhages are the second most common location.
· Cerebellar hemorrhages are the most common surgically managed ICH.
· Cortical ICH is less likely to require surgical intervention.
· Patients with cerebellar hemorrhages may have a rapid deterioration of clinical symptoms.
· Extension of blood into the ventricular system common and may lead to obstructive hydrocephalus and a resultant abrupt increase in intracranial pressure (ICP).
· Patients are often significantly hypertensive, as this is a major risk factor for the development of the disease. Patients with ICH often require aggressive blood pressure management. Despite controversy in this area, consensus recommendations exist for patients with systolic BP’s greater than 180 mm Hg. Modest reductions can be made in patients with systolic BP’s between 180 and 200; more aggressive approaches should be made for systolic BP’s over 200.
· Agents should be administered parentally.
o Hisorically, nitroprusside has been the agent of choice due to its rapid onset and ease of titration; however concerns have been raised about the risk for worsening hemorrhage due to the vasodilatory effects of the drug.
o Labetolol is another acceptable option.
o Nicardipine, a calcium channel blocker which works by decreasing peripheral vascular resistance, is the newest drug which is seeing use for this indication.
· Frequent BP monitoring should be undertaken and where concern is present for increased ICP (specifically in patients with intraventricular extension), intracerebral monitoring is recommended.
Linda Regan, MD FACEP
Program Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions