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Understand and Prevent Stroke





(45) Stroke

 What Is A Stroke? - Narration and Animation

stroke infographic1

Intracerebral hemorrhage (ICH)

 (Doctor only)

We will consider spontaneous hemorrhage into the brain parenchyma and ventricles (intracerebral hemorrhage, ICH). Non-traumatic bleeding into the subarachnoid space (subarachnoid hemorrhage, SAH) will be covered later.


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(46) Stroke

Hemorrhagic Stroke


Diagnosis and evaluation

Intracerebral hemorrhage (ICH)

 (Doctor only)

Stroke affects 0, 2% of the entire population, and more than 1% of people older than 65% years, each year. Stroke is fatal in up to one-third of cases, making it the third most common cause of death in developed countries, after coronary heart disease and cancer.


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(47) Stroke

Stroke: Causes, Symptoms, and Recovery

What is stroke?



Intracerebral hemorrhage (ICH)

 . Occurs in 20–35% of ICH:

- All locations;

- Usually in the first few hours after onset of symptoms but almost always in the first 24 hours;

- May occur later in patients with coagulopathy (coumadin);

- Associated with much worse prognosis.

. Aggressive blood-pressure reduction to SBP <-150, MAP 100–110 may reduce hemorrhage enlargement.

- Unproven (trials ongoing).

. Activated factor VII (NovoSeven).

- Recent phase II trial data suggest that hemorrhage growth can be prevented by giving activated factor VII, 40–160 mg/kg.

- This drug (NovoSeven) is expensive and can have dose related occlusive complications such as stroke, myocardial infarction, pulmonary embolism, etc.

- Pending further data and recommendations, we are using this drug (80 mg/kg, single dose IV) in patients with ICH if it can be started within four hours of symptom onset or if the ICH is associated with coagulopathy.

Patients with associated arterial occlusive diseases (coronary or cerebral ischemia, peripheral vascular disease, or pulmonary embolus), or who have already herniated, are not considered.


Goal: normal INR using fresh frozen plasma (FFP) 20 mL/kg and vitamin K*

. CT brain immediately.

. INR, PTT, thrombin time, D-dimers, fibrinogen, CBC.

. Type and cross, order 4 units of fresh frozen plasma (FFP).

. Give vitamin K 10mg IV over 10 minutes AND half of FFP (10 mL/kg). One unit of FFP ¼200–250 mL. Give diuretics if needed.

. Repeat INR and FFP 10 mL/kg every 20–30 minutes until INR is normalized.

. Activated factor VII (NovoSeven) (see above). Dose may be reduced to 20–40 mg/kg and repeated.


. Stop heparin.

. CT brain immediately.

. INR, PTT, platelets, CBC, fibrinogen, thrombin time, D-dimers.

. Type and cross.

. Give protamine: 25mg initial dose; check stat PTT 10 minutes later and if increased give 10mg additionally; repeat until PTT normal.*


Does lowering blood pressure cause ischemia or reduce the risk of rebleeding?

. The simple answer is that we don’t know. There is a debate as to whether there is an ischemic region around the hematoma.

Various studies using various techniques have resulted in conflicting data, but the general consensus is that ischemia is not a major cause of damage except with very large hematomas.

The consensus is that it is safe to lower a very high blood pressure.

. The risk of hematoma enlargement has been associated with increasing BP, with decreased risk associated with systolic blood pressures (SBP) < -150mm Hg, but whether lowering the blood pressure reduces the risk is unknown.

. The AHA/ASA guidelines recommend mean blood pressure (MAP) goal of 130mmHg* but it is poor-quality evidence (level of evidence V, grade C recommendation). It is possible that lower MAP (e.g., around 110mm Hg) would result in better outcome, but this remains to be tested.

. Until we have more data, we tend to be aggressive in lowering SBP to 150 and MAP to 100–120mmHg in the first 12–24 hours post-ICH.

- Use titratable drugs such as nicardipine and labetalol:

. Nicardipine 5mg/hr and titrate up to 15mg/hr as needed;

. Labetalol 10–20mg IV bolus, repeat as needed up to 60mg.

- Avoid nitroprusside.

- Other antihypertensive agents are usually not effective in the ED for accelerated hypertension associated with ICH.


. Continue to control blood pressure but maintain CPP>70mm Hg.

. Goal ICP<20mm Hg:

- Ventricular drainage.

- Ventricular drainage recently coupled with instillation of thrombolytics into the ventricle to accelerate ventricular clot dissolutionanddrainage ofCSF(unproven– trialsunderway).

. Maintain euvolemia, normothermia.

. Watch for neurologic deterioration.

. Withhold all antithrombotic drugs for 2 weeks.

- Compression stockings to prevent DVT.

- Uncertain when to start DVT prophylaxis with SC heparin or low molecular weight heparin, but probably wait at least 24 hours to be sure that no hemorrhagic enlargement is

occurring and that coagulation parameters are normalized.

. Talk with family about expected quality of life, advanced directives, withdrawal of support if appropriate.

. Start working on disposition early: rehab consult, case manager.

Prognosis and outcome


(The ranking is our impression):

Cause 1: rebleeding.

Cause 2: hydrocephalus (might itself be due to rebleeding).

Cause 3: cerebral edema.

Cause 4: general medical problems (infection, MI, electrolyte imbalance, pulmonary emboli).


Correlates with initial GCS, size of hematoma, and presence of IVH.

. GCS<9 and ICH volume>60 cc: 90% 1-month mortality

. GCS > - 9 and ICH volume<30 cc: 17% 1-month mortality

Also see the ICH score in Appendix 14.84

. ICH score > -5: close to 100% 1-month mortality

. ICH score > -4:>90% 1-month mortality

. ICH score¼2: 20–30% 1-month mortality

. ICH score -<1:<15% 1-month mortality

But also remember that it can be a ‘‘self-fulfilling prophecy.’’ If one treats with the expectation that the patient will do badly, the patient will do badly.



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