Treatment of intracerebral haemorrhage

The treatment of intracerebral haemorrhage is dependent upon the aetiology and the size of the lesion.

Vitamin K, or fresh frozen plasma should be given to reverse warfarin anticoagulation.

Blood pressure control for people with acute intracerebral haemorrhage

• Blood pressure management and ICH (1)
  • consider rapid blood pressure lowering for people with acute intracerebral haemorrhage who do not have any of the exclusions * and who:
    • present within 6 hours of symptom onset and
    • have a systolic blood pressure of between 150 and 220 mmHg
      
      
  • taking into account the risk of harm, consider rapid blood pressure lowering on a case-by-case basis for people with acute intracerebral haemorrhage who do not have any of the exclusions listed * and who:
    • present beyond 6 hours of symptom onset or
    • have a systolic blood pressure greater than 220 mmHg
      
      
  • when rapidly lowering blood pressure in people with acute intracerebral haemorrhage, aim to reach a systolic blood pressure of 140 mmHg or lower while ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment
    
    
  • when considering blood pressure lowering in young people aged 16 or 17 with acute intracerebral haemorrhage who do not have any of the exclusions listed*, seek advice from a paediatric specialist
    
    
  • * exclusions:
    • do not offer rapid blood pressure lowering to people who:
      • have an underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)
      • have a score on the Glasgow Coma Scale of below 6
      • are going to have early neurosurgery to evacuate the haematoma
      • have a massive haematoma with a poor expected prognosis
        
        
  • the NICE committee noted:
    • committee decided to remove the aim of reaching the target within 1 hour because only a minority (33.4%) of participants in the INTERACT2 trial achieved the target of 140 mmHg within 1 hour and, more importantly, to avoid the potential harm of reducing systolic blood pressure by more than 60 mmHg in the first hour
    • was evidence that rapidly lowering blood pressure does not increase the risk of neurological deterioration caused by reduced blood flow to the brain and has the potential to improve quality of life
    • agreed that while there is some evidence that rapid blood pressure lowering treatment is beneficial, there may be an increase in adverse renal events, and they were concerned about the lack of evidence in people who are frail
    • evidence that a moderate reduction of up to 60 mmHg within the first hour was associated with better outcomes such as functional independence
      • a reduction of more than 60 mmHg within 1 hour was associated with significantly worse outcomes such as renal failure, early neurological deterioration, and death, compared with standard treatment
      • therefore, the committee agreed that a large reduction of 60 mmHg or more within 1 hour should be avoided

Reversal of anticoagulation treatment in people with haemorrhagic stroke

• return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke (and have elevated international normalised ratio)
  • achieved by reversing the effects of the warfarin using a combination of prothrombin complex concentrate and intravenous vitamin K

Small haematomas typically resolve spontaneously. Massive haematomas are associated with devastating neurological signs and often present too late for effective treatment.

Medium size haematomas can be decompressed either:

• medically - methods used include intubation with forced hyperventilation, mannitol or glycerol, or corticosteroids
• surgically

NICE state that (1):

• Surgical referral for acute intracerebral haemorrhage
  • stroke services should agree protocols for the monitoring, referral and transfer of people to regional neurosurgical centres for the management of symptomatic hydrocephalus
  • people with intracranial haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary
  • previously fit people should be considered for surgical intervention following primary intracranial haemorrhage if they have hydrocephalus
  • people with any of the following rarely require surgical intervention and should receive medical treatment initially:
    • small deep haemorrhages
    • lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
    • a large haemorrhage and significant comorbidities before the stroke
    • a score on the Glasgow Coma Scale of below 8 unless this is because of hydrocephalus
    • posterior fossa haemorrhage

Reference:

• (1)NICE (April 2022). Stroke and transient ischaemic attack in over 16s: diagnosis and initial management