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Acute Management of Intracerebral Haemorrhage (ICH)

General ICH Management Guidelines

Many aspects of acute management of intracerebral haemorrhage (ICH) are similar to ischaemic stroke, particularly the benefit of stroke unit care, maintenance of homeostasis, and early rehabilitation. There are some important differences, however:

• Avoid aspirin, heparins, thrombolytic agents.
• Full coagulation screen is required urgently.
• If taking oral anticoagulants, this is a life-threatening emergency and immediate action to reverse the anticoagulant effect is required (if this is possible). See Intracerebral Haemorrhage while on Warfarin: Reversal of the Warfarin-related Coagulopathy or Bleeding following Dabigatran, as appropriate.
• Acute BP management: the threshold for considering use of IV antihypertensive agents in the acute phase of stroke is lower in patients with ICH (>180/105) compared with ischaemic stroke (>220/120). Antihypertensive agents as for ischaemic stroke.

  Note: There is evidence a lower target of 140 mm Hg systolic is safe in acute ICH, but that this confers only marginal additional clinical benefit to the patient.

• Neurosurgical referral should be considered for potentially life-threatening ICH in previously neurologically well patients who have:
  • Cerebellar ICH.
  • Superficial supratentorial ICH.

Investigations

• CT head scan - "hypertensive" deep ICH can be usually diagnosed on clinical grounds with plain CT and does not usually require additional investigation:
  • Further vascular imaging is generally not indicated in patients if:
    • ICH in deep (basal ganglia) location - territory of the penetrating arteries.
    • Patient is clinically hypertensive or has a history of treated hypertension.
    • Patient is >45 y in age.
• Investigation for possible underlying vascular disorders may be indicated in other patients. The first investigation is usually MRI. The best timing for this investigation depends on clinical factors, including the patient's prognosis for survival, and the size and location of the ICH. Neurological/Neurosurgical or Neuroradiological advice is recommended.

  Note: Investigations for vascular cause are usually deferred until the patient is clinically stable from their acute ICH. This does not apply to patients with subarachnoid haemorrhage, which is a neurosurgical emergency.

• CBC + diff.
• Coagulation screen.

Intracerebral Haemorrhage while on Warfarin: Reversal of the Warfarin-related Coagulopathy

Background

• Intracerebral haemorrhage in a patient taking warfarin is a medical emergency with a mortality of between 43-70% at 30 days.
• ICH volume is not maximal at the outset but expansion of a primary ICH can continue for several hours (without warfarin). If taking warfarin at the time of bleed, ongoing bleeding can continue for 24-48 hours. ICH volume and further expansion of ICH are both independent predictors of mortality.
• Most warfarin related ICHs occur with the INR within the "therapeutic" range.
• Warfarin causes functional deficiencies of several different clotting factors which require replacement. Furthermore, this needs to occur urgently to reduce ICH expansion.

Reversal Guidelines

• All patients with both an acute intracerebral haemorrhage and taking warfarin should have immediate intravenous reversal of the coagulopathy without waiting for the result of an INR.
• Consider reversal before CT-confirmed diagnosis if high level of suspicion. Discuss with Consultant.
• Take the warfarin reversal pack (kept in ED) with the patient to CT and administer reversal as soon as ICH is diagnosed.
  • Stop warfarin.
  • Give vitamin K 10 mg IV immediately.
  • Give Prothrombinex VF 50 units/kg IV immediately. Complete the Blood Product Request QMR22B form with the required dose (50 units/kg). Write "Life-threatening bleed on warfarin" clearly on the form. Send in a Lamson tube to the Blood Bank or fax to Blood Bank (80159), then inform the New Zealand Blood Service doctor on call via phone (80310).
  • Give fresh frozen plasma (FFP) 150-300 mL.

Notes:

• In the setting of ICH, reversal of warfarin is urgent. You should not wait for an INR result because this delays reversal (time is brain). Also, reversal is indicated even if INR is in therapeutic range, or subtherapeutic, e.g., INR 1.7.
• Vitamin K takes 6-24 hours to be effective.
• Prothrombinex VF rapidly reverses the coagulopathy within 15 minutes. See also warfarin overdosage.
• If Prothrombinex VF is not available, vitamin K (as above) and larger doses of fresh frozen plasma (FFP) can be given (at a dose of 15-30 mL/kg) but produces suboptimal anticoagulation reversal.
• Monitoring:
  • INR alone is not useful for monitoring the effectiveness of clotting factor replacement. It is only useful for monitoring warfarin use in steady state situations.
  • Monitoring should be done immediately after treatment using a coagulation screen (INR, APTT, thrombin time and fibrinogen). If still abnormal, more coagulation factors should be given immediately.
  • If normal recheck in 4-6 hours (reflecting shortest half-life of factor VII and vitamin K onset of action).
  • If normal again, then recheck at 24 hours, or sooner if patient clinically unstable.
• The risk of thrombotic events during this short term reversal appears very low, even in patients with prosthetic heart valves.

Oral thrombin inhibitors (Dabigatran) related ICH

• Like warfarin-related ICH, these patients need urgent assessment in an attempt to minimize the extent of the ICH. No specific method of reversal is available. See Bleeding Following Dabigatran.

Longer term management

• This requires an individual assessment of the risks and benefits of restarting warfarin or not. Most should not restart warfarin, but it is dependent on indications for anticoagulation, location and severity of bleed, comorbidities, age and concurrent medications.

Topic Code: 17278