Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage

Abstract

Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.

Keywords: Intracerebral hemorrhage; Prognosis; Hematoma expansion; Inflammation; Hemostatic therapy; Oral anticoagulants

Core tip: Spontaneous intracerebral hemorrhage is associated with poor outcome. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Nihilism and early withdrawal of active therapy clearly influence the outcome. Action should be taken fast and accurately. Treatment should be individualized and guided preferably by pathophysiology in a multidisciplinary team work. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure.