CONTENTS

• Rapid Reference 🚀
• Pathophysiology
• Differential diagnosis & causes
• Imaging
  • Noncontrast CT scan
  • Evaluation for an underlying etiology
• Treatment
  • Airway management
  • Anticoagulation reversal
  • Blood pressure management
  • Neurosurgical interventions
  • Seizure monitoring & management
  • Other supportive measures
• Prognostication
• Intraventricular hemorrhage
• Podcast
• Questions & discussion
• Pitfalls

---

rapid reference

(back to contents)

---

Intracerebral hemorrhage checklist ✅

history – key information

• Time of symptom initiation.
• Medications (especially antihypertensives & anticoagulants – including timing of the last dose).

admission lab panel

• Electrolytes (including Ca/Mg/Phos, glucose).
• Complete blood count (CBC).
• INR, PTT, fibrinogen.
• May consider TEG (if cirrhosis, DIC, or complex coagulopathy is suspected).
• Toxicology screen if clinically warranted.
• Pregnancy evaluation as appropriate.
• ABG/VBG if patient is intubated.

anticoagulation reversal

• Warfarin reversal: 📖
• Dabigatran reversal: 📖
• Xaban reversal: 📖
• Thrombolysis reversal: 📖
• Heparin reversal: 📖
• Antiplatelet reversal: 📖

neurosurg consultation – especially: 📖

• Consider hematoma evacuation in cerebellar hemorrhage.
• Consider ventricular drain in hydrocephalus.

blood pressure control 📖

• Target systolic blood pressure <180 mm.
• Preferred agents: PRN labetalol boluses starting at 10 mg, or infusion of nicardipine or clevidipine.

other

• Aggressive fever control (scheduled acetaminophen, physical cooling PRN).
• Avoid hyponatremia.
• EEG if altered mental status is disproportionately severe compared to abnormality on CT scan, or if there is other evidence of seizure.
• Repeat CT scan.  Add a CT angiogram/venogram if suspicion for secondary hemorrhage (e.g., patient doesn’t fit pattern of hemorrhage due to chronic hypertension).📖

---

pathophysiology

(back to contents)

---

• Most non-traumatic primary intracerebral hemorrhages are due to hypertension.  They have a preponderance to occur in the same locations in which patients develop lacunar strokes, and have the same underlying process: arteriolar lipohyalinization in end arterioles.  These locations include: cerebellum, pons, thalamus and basal ganglia.  Secondary causes of intracerebral hemorrhages are multiple – see below for more.
• Hematoma expansion:
  • Up to a third of patients whose CT is obtained within 3 hours of onset will experience an increase in hematoma size.  Among patients who are on therapeutic anticoagulation, this risk increases to ~50%.(Torbey, 2019)
  • Hematoma expansion is most common within the first 6 hours (yet it can occur within ~48 hours in coagulopathic patients).
• Cytotoxic edema surrounding the hematoma (perihematomal edema) worsens over a period of days, before improving.  Edema volume may peak after ~5-6 days.(Shutter 2019)
  • Remember that cytotoxic edema does not respond to steroids – only vasogenic edema does.
• Intracranial pressure may increase due to the mass effect of the hemorrhage and the perihematomal edema, as well as either blood accumulation in the ventricles (if the hematoma extends into the ventricles) or mass effect on the ventricles leading to obstructive hydrocephalus.
• Terminology: remember that ICH refers to a primary or secondary non-traumatic hemorrhage. The term “hemorrhagic stroke” encompasses ICH, but also hemorrhagic conversion of an ischemic stroke and subarachnoid hemorrhage, and should be avoided in order to avoid confusion.

---

differential diagnosis & causes

(back to contents)

---

hypertensive intraparenchymal hemorrhage

• Location is most commonly:(26046515) 
  • Basal ganglia/external capsule (60-65%).
  • Thalamus (15-20%).
  • Cerebellum or pons (10%).
• Epidemiology:
  • Causes ~80% of all intracranial hemorrhage.(Torbey, 2019)
  • Risk factors include age, hypertension, and diabetes.
  • Supported by other evidence of hypertension (e.g., left ventricular hypertension, chronic kidney disease).
• Imaging often reveals additional chronic white matter changes and microhemorrhages (the latter may be seen on GRE/SWI MRI sequences).

cerebral amyloid angiopathy

• Location:
  • Usually lobar hemorrhage, more often in the occipital and parietal lobes.(29262441)
  • Sometimes with subarachnoid extension or finger-like projections of the hemorrhage (image below).
  • 💡 Hint:  If the patient has underlying cognitive decline, and the hemorrhage is lobar/cortical and with a small degree of high cortical subarachnoid hemorrhage, chances are you are looking at an amyloid hemorrhage.
• Epidemiology:
  • Cerebral amyloid angiopathy has a prevalence of ~5% among people >65YO, accounting for ~15% of all spontaneous intracranial hemorrhages.(34618759)
  • This is the most common cause of lobar hemorrhage in normotensive elderly patients.  However, half of lobar ICH in the elderly aren't due to amyloid angiopathy, so these two factors alone do not establish the underlying mechanism of the hemorrhage.(32299594)
  • It is often provoked by anticoagulation or thrombolysis.
• GRE/SWI sequences on MRI may show additional microhemorrhages at the gray-white junction and/or convexity hemosiderosis.👇
• The short-term prognosis is often favorable, but there is a high risk of hemorrhage recurrence (~7.5%/year) and subsequent cognitive decline.(32299594)  
• 💡 If you diagnose with someone with cerebral amyloid angiopathy, those patients should not be restarted on anticoagulation as they carry a very high risk of recurrent hemorrhage.

aneurysmal rupture

• Potential clues:
  • (1) Aneurysms usually have at least a small subarachnoid component, along with the intraparenchymal hematoma.(29262441)
  • (2) Often frontal location (due to aneurysm of the ACA or AComm) or temporal location (due to aneurysm of the MCA). 📖  The hematoma may extend down to a vessel within the circle of Willis.
  • (3) Relatively young patients.
• The aneurysmal nature is usually diagnosed based on CT angiography.📖
• Management:
  • Consult neurosurgery and/or interventional radiology for aneurysmal protection.
  • Manage blood pressure similarly to the guidelines for subarachnoid hemorrhage.(Torbey, 2019)

other vascular malformations

• Types include:
  • Arteriovenous malformation (AVM).
  • Cavernous malformation (aka., cavernomas or cavernous hemangiomas).  These are notable for their unique popcorn-like appearance on T2 MRI images.
  • Dural arteriovenous fistula (dAVF) usually involve the cerebral convexity.
  • Mycotic aneurysm (may result from endocarditis or bacteremia).
• Treatment implication:  Vascular malformations often require surgical resection and/or embolization by interventional radiology to avoid re-bleeding.

malignancy

• Metastasis:
  • Metastases which are especially prone towards bleeding:  renal cell carcinoma, melanoma, choriocarcinoma, papillary thyroid carcinoma.
  • The most common causes of hemorrhage are lung or breast carcinoma (because they are more common overall).
  • Metastases tend to occur at the junction of the gray and white matter, so this may lead to lobar hemorrhages.(32299594)
• Primary CNS tumor (e.g., glioblastoma, oligodendroglial tumors).
• Potential radiological clues:
  • (1) Edema out of proportion to hemorrhage.
  • (2) Edema present at an early time point, when hemorrhage-related edema wouldn't be expected.(32299594)
  • (3) A hypodense or hyperdense tumor core may be visible within the hematoma.(29262441)
  • (4) Nodular enhancement, or persistent enhancement over time.(26046515)  However, a large hematoma may initially obscure the underlying malignancy.  

ischemic stroke with hemorrhagic conversion

• See the chapter on acute ischemic stroke: 📖

cerebral venous thrombosis (CVT) with secondary hemorrhage

• Epidemiology:  Risk factors include hypercoagulability, dehydration, pregnancy, parameningeal infection, lupus, inflammatory bowel disease, and thyroid disease.(30938800)  This accounts for 5% of parenchymal hemorrhage in younger patients.
• Pathophysiology:  can represent either a primary venous hemorrhage related to venous congestion, or a secondary hemorrhagic conversion of an area of ischemia caused by venous congestion. Management, however, is the same in both cases.
• Imaging clues for the diagnosis of cerebral venous thrombosis.📖
• Treatment implication:  Transvenous thrombectomy and/or anticoagulation may be needed.

less common causes 

• Trauma: 📖
• Vasculitis:  Epidemiology:  Usually caused by polyarteritis nodosa or lupus, but may also occur with ANCA vasculitis, rheumatoid arthritis, sarcoidosis, drug-induced vasculitis, or Henoch-Schonlein purpura.
• RCVS: 📖
• Moyamoya disease
  • Chronic, progressive, spontaneous occlusive disease involving the internal carotid artery and associated vasculature.  May be bilateral or unilateral.
  • Among adults, the peak incidence occurs among patients in their 40s.
  • Moyamoya disease most often presents with an ischemic event, but about a third of patients may present with an intracranial hemorrhage resulting from fragile collaterals and/or false aneurysms.(34618759)  ICH is most commonly located in the basal ganglia.
• Coagulopathy.

---

noncontrast CT scan

(back to contents)

---

diagnosis

• Noncontrast CT scan is the standard diagnostic test to rapidly evaluate for intracranial hemorrhage.

hematoma volume

• Hematoma volume may be estimated as the multiple of the diameters divided by two (ABC/2). 🧮
  • A is the largest hematoma diameter on any axial CT image.
  • B is the largest diameter perpendicular to A, within that axial CT slice.
  • C is the number of axial CT slices showing hemorrhage, multiplied by the slice thickness (which may vary from 3-10 mm depending on the scanner).(34618759)  This should only include slices with at least 75% of the hematoma volume.  Alternatively, this may be measured as the height of the hematoma, when measured in sagittal or coronal plane (figure below).
• All measurements should be made in centimeters.  This will yield a volume measured in milliliters (mL).
• Volume >60 ml suggests a worse prognosis (more below).

markers of hemorrhage expansion on noncontrast CT

• Black hole sign
  • Defined as a relatively hypo-attenuated area within a hematoma that is not connected with adjacent brain tissue.
  • Predicts hematoma growth with 32% sensitivity and 94% specificity.
• Fluid-fluid level:  Fluid level in a hematoma suggests the presence of coagulopathy.  This finding is only moderately sensitive, but it is specific.(32299594)
• Blend sign:  Hemorrhage contains hyperdense and hypodense regions.
• Island sign:  At least three small hemorrhages which are separated from the main hemorrhage.(32224753)

serial CT scan?

• Hematoma expansion will often occur within 6 hours (or longer in anticoagulated patients).
• In patients without an accessible neurologic examination (e.g., due to sedation), consider a repeat CT scan in 4-6 hours.  If hydrocephalus develops, this may be an indication for external ventricular drain placement.📖

---

evaluation for an underlying etiology

(back to contents)

---

when to suspect an underlying vascular intracranial pathology 🧐

• Identification of underlying vascular pathology is potentially important, as many of these lesions require specific therapy.
• Factors which increase the likelihood of an underlying vascular pathology include:
  • (1) Imaging findings on noncontrast CT scan
    • Hematoma located outside of the typical location for a hypertensive hemorrhage (e.g., lobar or infratentorial hemorrhage).
    • Fluid level within the hematoma.
    • Isolated intraventricular hemorrhage.
    • Calcified or dilated vessels.
    • Abnormal parenchyma surrounding the hematoma (e.g., more edema than might be expected).
  • (2) Epidemiological findings
    • Younger age (e.g. <65 YO).
    • Female sex.
    • No history of hypertension.
    • No coagulopathy.

CT angiography (+/- CT venography)

• This is the front-line test to evaluate for an underlying cause of ICH due to speed and safety (especially for causes which require more immediate management).
  • CT angiography may be useful to detect an underlying aneurysm or vascular malformation.
  • CT venography may be useful to diagnose venous sinus thrombosis.
  • Both CT angiography and venography may be performed together (CTAV).
• Prognostication of the risk of hematoma expansion
  • This isn't the reason for obtaining CT angiography, but it may be helpful nonetheless.
  • The spot sign reveals leakage of contrast into the hematoma (predicting expansion with 51% sensitivity and 85% specificity).
  • The spot sign must not be in anatomic continuity with any adjacent blood vessels.(32224753)
• ⚠️ Please note that contrast dye is not nephrotoxic.📖  Appropriate imaging should not be deferred due to renal dysfunction.  

MRI

• This generally isn't performed immediately, due to logistic constraints, but should be performed within 2 days of ictus if you wish to administer gadolinium.  The reason is that after 2 days, the blood becomes hyperintense on T1 and you may not be able to see beneath the hemorrhage when the gadolinium is administered.  If you are searching for amyloid, a non-gadolinium enhanced MRI will suffice.
• MRI may be superior for detecting certain underlying pathologies:
  • Tumor.
  • Ischemic stroke with hemorrhagic transformation.
  • Amyloid angiopathy with multiple occult cerebral micro-bleeds.
  • Underlying hypertensive microangiopathy (may be suggested by white matter lesions and small lacunar strokes).
• MR angiography can image the vessels, so this may be considered as well (especially if a CT angiography hasn't been performed).

invasive angiography (aka, digital subtraction angiography)

• This is the definitive study to evaluate for aneurysm, dural arteriovenous malformation (dAVF), or vasculitis.
• This is indicated if there is a high suspicion for vascular abnormality (e.g., ruptured aneurysm ).(31092052)
• Angiography can be both diagnostic and therapeutic (if an aneurysm or arteriovenous malformation is discovered, some may be embolized immediately).
• Consider angiograms in patients with hemorrhages in unusual locations, or in younger patients (<50 years old).

---

airway management

(back to contents)

---

• Intubation may be required for airway protection.  However two thirds of patients won't require intubation.(31092052)
• There are no validated or well-defined criteria for intubation – this is a clinical judgement based on examination and trajectory.
• Care is required to avoid stimulation and hypertension, which could worsen intracranial pressure elevation.🌊

---

anticoagulation reversal

(back to contents)

---

anticoagulant reversal

• Assess coagulation thoroughly (including both laboratory tests and medication review).
• Platelet function
  • Thrombocytopenia should be treated, to maintain a platelet count >100,000 if possible.
  • There is no benefit in platelet transfusion for patients who had been treated with aspirin or anti-platelet agents (PATCH trial), with the possible exception of patients undergoing neurosurgery.(27178479) 
  • DDAVP administration may be considered.📖
• Therapeutic anticoagulation (e.g., warfarin, NOACs) should be aggressively reversed.📖
• More on anticoagulation reversal:
  • Warfarin reversal: 📖
  • Dabigatran reversal: 📖
  • Xaban reversal: 📖
  • Thrombolysis reversal: 📖
  • Heparin reversal: 📖
  • Antiplatelet reversal: 📖

---

blood pressure management

(back to contents)

---

theoretical rationale & risks

• Rationale:  Blood pressure reduction could theoretically reduce hematoma expansion.  This would be expected to be most effective within the period that the hematoma is expanding (typically the first six hours, but potentially longer in coagulopathic patients).
• Risks
  • Neurological:  Reduced blood pressure could impair perfusion of penumbra surrounding the hematoma.  This could cause necrosis, leading to worsening edema and intracranial pressure (leading to a cascade of secondary brain insults).
  • Renal failure may result from excessive blood pressure reduction.

targets?

• 📊 INTERACT-2 Trial in 2013 (23713578) 
  • RCT comparing a target of SBP <140 mm versus SBP <180 mm for a seven-day period among >2,800 patients within <6 hours of symptom onset.
  • The primary endpoint of death or disability after 90 days showed no benefit.  Likewise, there was no difference in the incidence of hematoma expansion (table above).
  • There was a tiny improvement in a secondary endpoint (quality of life) in the more aggressively treated group.  However, given that there was no difference in hematoma expansion, this isolated secondary endpoint is of dubious significance.
  • The most commonly used antihypertensive agent was urapidil (an alpha-blocker), which may limit generalizability.
  • This study has been traditionally used to justify the systolic Bp target of <140 mm.
• 📊 ATACH-2 trial in 2016 (27276234)
  • This was a follow-up study to INTERACT-2, which likewise compared SBP targets of 110-140 mm versus 140-180 mm.
  • This study utilized intravenous nicardipine, which more closely resembles typical practice patterns.
  • There was no benefit to more intensive blood pressure reduction (either in terms of functional endpoints or in terms of hematoma expansion).
  • More aggressive reductions in Bp increased the risk of renal adverse events (from 4% to 9%, p=0.002).  
• Guidelines?
  • 🛣 American Heart Association / American Stroke Association (AHA/ASA) suggest reduction in a systolic blood pressure below 140 mm.  However, these guidelines were written in 2015, prior to the ATACH-2 trial. (26022637)  
  • 🛣 American Heart Association / American College of Cardiology guidelines from 2017 recommend against acutely lowering the systolic blood pressure below 140 mm (figure below 👇).(29133354)  
• Bottom line?
  • Despite repeated and well-powered trials, there is no evidence that more intensive blood pressure control can improve hematoma size.  If lower blood pressure isn't reducing hematoma size, then it may be only harming patients due to hypoperfusion of compressed penumbra tissue.
  • Targeting a systolic blood pressure <180 mm is consistent with available evidence and the most recent guidelines (shown below).  (29133354)  
    • If you shoot for a systolic Bp <180 mm, then you'll often end up with a systolic Bp around ~140-160 mm, which is good.
    • If you shoot for a systolic Bp <140 mm, then you'll often end up with a systolic Bp around ~100-120 mm, which is probably too low.
  • ⚠️ Before initiating antihypertensives, always make sure that pain and anxiety have been adequately treated.  Especially among intubated patients, hypertension can be a manifestation of pain.  Proper analgesia and sedation may go a long way towards reduction of the blood pressure.

preferred agents

• Nicardipine 💉 or clevidipine 💉 infusion is the most common and effective approach to severely elevated blood pressure.
• Small labetalol 💉 boluses may be used PRN if the blood pressure is slightly above target (e.g., 10-20 mg IV every 15 minutes PRN).

---

neurosurgical interventions

(back to contents)

---

surgical hematoma evacuation for supratentorial hemorrhage

• 📊 STITCH-I Trial (15680453)
  • RCT involving 1,033 patients randomized to medical management vs. early surgical hematoma evacuation.
  • Outcomes were nearly identical between two groups.  However, there was a non-significant trend toward benefit from surgery in patients with hematoma extending to within 1 cm of the cortical surface.  Likewise, there were trends toward benefit from early surgery among patients with lobar hemorrhage and Glasgow Coma Scale score of 9-12.
  • Patients with ICH >1 cm from cortical surface or GCS<9 tended to do worse with surgery.
• 📊 STITCH-II Trial (23726393)
  • RCT involving 601 patients predicted to obtain maximal benefit from surgery based on the results of the STITCH-1 trial (patients were conscious, had superficial hemorrhage <1 cm from the cortical surface, had a hemorrhage volume of 10-100 ml, and had no intraventricular hemorrhage).
  • Patients were randomized to early surgery vs. early conservative approach.
  • Outcomes were nearly identical between the two groups.
• Evidence summary:
  • Available evidence suggests no outcome benefit for early hematoma evacuation.  Some patients in the medical arm of these studies did cross over into the surgical arm due to progressive deterioration, so surgery might still be beneficial in selected cases with progressive deterioration over time.
  • Emerging evidence suggests that minimally invasive surgery could be more promising (with several ongoing trials).
• Possible indications for surgery?
  • Large hematoma with significant midline shift.
  • Elevated ICP refractory to medical management.
  • Hemorrhage secondary to an underlying lesion that could benefit from resection (e.g., arteriovenous malformation or tumor).

surgical hematoma evacuation for cerebellar hemorrhage

• The cerebellum is somewhat unique due to its enclosed location.  Swelling in the cerebellum threatens to cause catastrophic damage to the adjacent brainstem, and also leads to pinching off CSF flow due to obstructive compression of the fourth ventricle which rapidly leads to obstructive hydrocephalus. Cerebellar patients also tend to have better prognosis than other types of hemorrhage. Put together, this implies a greater benefit for hematoma evacuation in this location.
• Ventriculostomy placement without decompression and/or hematoma evacuation is not recommended, as this increases the chances of causing upward transtentorial brain herniation.
• No RCTs exist (these patients were excluded from the STITCH trials..
• Observational data suggests benefit in the following situations:
  • Hematoma >3 cm diameter.
  • Mass effect causing brainstem compression or herniation.
  • Hydrocephalus due to ventricular obstruction. (Note that management with an external ventricular drain alone in this situation may lead to upward herniation of the posterior fossa.  Thus, an external ventricular drain should be combined with hematoma evacuation).(33952393)

external ventricular drain (EVD)

• Ventricular drainage may be considered for hydrocephalus (e.g., due to ventricular extension of the hemorrhage).
• An ideal candidate might be a patient who was initially doing well, then subsequently developed hydrocephalus with neurologic deterioration.
• Unfortunately, overall evidence suggests that ventricular drainage increases survival without increasing the likelihood of a good neurologic outcome.  This implies that patients whose lives are saved by drain placement generally have poor neurologic outcome. (10751114, 22732889)

intrathecal tPA

• There has been some interest in the utility of intrathecal/intraventricular tPA, to promote dissolution of thrombus following intraventricular hemorrhage.
• Intrathecal/intraventricular tPA has been safely studied to assess improvement in outcome or mortality and was published as the CLEAR III trial.(28081952)
  • 500 patients were randomized to receive intrathecal tPA vs. saline.
  • Unfortunately, this trial demonstrated no clear mortality benefit with intrathecal tPA use.
• Intrathecal tPA is still used in some centers, particularly when it is felt that the patient primordially has IVH without significant ICH, and when the hydrocephalus might resolve if the IVH dissipates.

---

seizure diagnosis & management

(back to contents)

---

seizure prophylaxis isn't generally recommended

• Clinical seizures occur in ~10% of patients, but the rate of subclinical seizures may be substantially higher.(34618759, LaRoche 2018)
• Patients with cortical involvement are at higher risk.
• Prior evidence has not revealed benefit with prophylactic phenytoin (which may relate to phenytoin's numerous side-effects).
• Whether seizure prophylaxis with more modern agents (e.g., levetiracetam) could be beneficial remains unknown.

monitoring & diagnosis

• Indications for continuous EEG:
  • Impaired consciousness that is out of proportion to what would be expected based on the CT scan.
  • Unexplained fluctuations in mental status.
  • Any history or clinical signs of seizure.
  • (More on the indications for continuous EEG monitoring: 📖)
• ICH may also be associated with lateralized periodic discharges, generalized periodic discharges, stimulus-induced rhythmic periodic or ictal discharges (SIRPIDs), and frontally predominant intermittent rhythmic delta activity (FIRDA).(LaRoche 2018)

management

• Antiepileptic therapy is indicated for a patient with witnessed seizure, electroencephalographic seizure, or nonconvulsive status epilepticus. 📖

---

other supportive measures

(back to contents)

---

fever control

• Any fever should be treated aggressively (e.g., with scheduled acetaminophen).
• If fever is refractory to antipyretics, an external cooling device may be used to achieve aggressive normothermia (similar to treatment of a post-arrest patient).
• Neurogenic fever may occur, especially among patients with intraventricular extension of the hematoma.(33952393)  However, this remains a diagnosis of exclusion.📖

sodium management

• Avoid hyponatremia or rapid decreases in sodium.
• Routine use of hypertonic saline isn't supported by evidence.
• Boluses of hypertonic saline or hypertonic bicarbonate may be used to manage elevated intracranial pressure, ideally as a bridge to more definitive therapy (e.g., an external ventricular drain).

DVT prophylaxis

• Intermittent pneumatic compression should be used initially for DVT prophylaxis.
• Heparin for DVT prophylaxis is generally safe >48 hours after initial bleed, if there has been no hematoma expansion on repeat CT scan.(1865215)

---

prognostication

(back to contents)

---

overall prognosis

• Mortality is high, with only half of patients alive after one year and only ~30% alive after five years.
• Only ~20% of patients overall remain alive and independently functioning after one year.

predictors of poor outcome

• Hematoma volume >60 ml.
• Glascow Coma Scale <8.
• Deep or infratentorial location.
• Intraventricular extension.
• Increasing age.

ICH score 🧮

• The ICH score is that it is designed to predict survival, rather than independent survival or quality of life.

FUNC score 🧮

• Estimates the likelihood of functional independence at 90 days, potentially a more meaningful endpoint.
• Tables below provide more granular detail about how the score is obtained and interpreted.(18556582) 

---

intraventricular hemorrhage

(back to contents)

---

basics

• Primary intraventricular hemorrhage refers to hemorrhage into ventricles without associated parenchymal ICH.
• Primary intraventricular hemorrhage is rare, accounting for 3% of nontraumatic intracranial hemorrhage.(34618759)

causes of intraventricular hemorrhage 

• ~90% are idiopathic.
• ~10% have an underlying etiology, including:
  • Hypertension.
  • Arteriovenous malformation (AVM), arteriovenous fistula, or aneurysm.
  • Moyamoya disease.
  • Coagulopathy.
  • Choroid plexus tumor or ependymal lesion.

role for external ventricular drain (EVD)

• Drainage is indicated for acute obstructive hydrocephalus.

---

podcast

(back to contents)

---

Follow us on iTunes

---

questions & discussion

(back to contents)

---

To keep this page small and fast, questions & discussion about this post can be found on another page here.

• For most patients, the best treatment seems to be high-quality supportive care.  Aggressive interventions (e.g., causing dramatic drops in blood pressure and “prophylactic” hypertonic saline) may cause more harm than good.
• Cerebellar hematomas may threaten brainstem compression as well as hydrocephalus, so these patients potentially benefit the most from urgent surgical evacuation and/or ventricular drainage.
• Steroid doesn't help ICH.  Don't use steroid in these patients unless there is some other indication.

Acknowledgement:  Thanks to Dr. Richard Choi (@rkchoi) for thoughtful comments on this chapter.

Guide to emoji hyperlinks 

•  = Link to online calculator.
•  = Link to Medscape monograph about a drug.
•  = Link to IBCC section about a drug.
•  = Link to IBCC section covering that topic.
•  = Link to FOAMed site with related information.
•  = Link to supplemental media.

Going further

• Radiopaedia (Craig Hacking and Jeremy Jones)
• Golden hour in intracerebral hemorrhage (EMCases with Anton Helman, Scott Weingart, and Salter Himmel)
• INTERACT-2 trial
  • WikEM Journal Club
  • EMNerd – The case of the differing perspectives
• ATACH-2 trial
  • TheBottomLine review by Adrian Wong
  • Intensive blood pressure control doesn't benefit patients with acute cerebral hemorrhage (RebelEM, Anand Swaminathan)
  • Don't bring my blood pressure down (intensively) – SGEM with Ken Milne