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Intracerebral Hemorrhage (ICH) Approach: Bedside Practical Review

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Neurosonology in Critical Care

Abstract

The delivery of neurocritical care for spontaneous intracerebral hemorrhage (ICH) is not so much the performance of a single lifesaving act but rather the careful management of multiple medical issues that taken together can improve the morbidity and mortality of this challenging condition. Since 1980, case fatality from ICH has not decreased over time with the exception of certain regions and only 10–20% of patients who survive hospitalization currently regain functional independence (Rincon and Mayer Neurocrit Care 19(1):95–102, 2013; van Asch et al. Lancet Neurol 9(2):167–176, 2010). It is not possible to point to one specific intervention or approach that has improved outcomes, so obtaining the best possible outcomes requires management of both the specific issues to ICH as well as general principles of high-quality critical care. In this chapter, we will review the approach to ICH from the practical perspective of the bedside practitioner.

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Authors and Affiliations

  1. Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA

    Thomas J. Cusack & Wendy Ziai

Authors
  1. Thomas J. Cusack
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  2. Wendy Ziai
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Corresponding author

Correspondence to Wendy Ziai .

Editor information

Editors and Affiliations

  1. Department of Critical Care, University of Buenos Aires, Buenos Aires, Argentina

    Camilo N. Rodríguez

  2. Stroke Unit & Neurosonology Lab, University of Padua School of Medicine, Padova, Italy

    Claudio Baracchini

  3. Department of Critical Care and Anesthesiology, Fundación Valle del Lili, Cali, Colombia

    Jorge H. Mejia-Mantilla

  4. Department of Clinical Neurosciences Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK

    Marek Czosnyka

  5. Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Jose I Suarez

  6. President of Hungarian Neurological Society, Department of Neurology, Clinical Center Debrecen University, Debrecen, Hungary

    László Csiba

  7. Intensive Care Unit, Clinics Hospital, Universidad de la Republica School of Medicine, Montevideo, Uruguay

    Corina Puppo

  8. Center for Neurological Vascular Diagnostics, Munich, Germany

    Eva Bartels

Appendices

Algorithm

figure a

ABCD airway-breathing-circulation-disability, PCC prothrombin complex concentrate, VKAs vitamin K antagonist, MRA magnetic resonance angiography, MRV magnetic resonance venography, NCx neurosurgery, FFP fresh frozen plasma, SBP systolic blood pressure

Appendix: Direct Oral Anticoagulant Reversal

After five half-lives, anticoagulation can be considered fully resolved.

Apixaban: 8–15 h; 5 half-lives: 24–75 h after last dose (day 1.5–3)

Betrixaban: 19–27 h; 5 half-lives: 95–135 h after last dose (day 4–5.5)

Dabigatran: 12–17 h; 5 half-lives: 60–85 h after last dose (day 2.5–3.5)

Edoxaban: 6–11 h; 5 half-lives: 30–55 h after last dose (day 1.3–2)

Rivaroxaban: 5–9 h; 5 half-lives: 30–45 h after last dose (day 1–2)

Activated charcoal to absorb drug if taken in prior:

Apixaban: up to 6 h

Edoxaban: up to 2 h

Rivaroxaban: up to 8 h

1.1 Reversal Strategies

Dabigatran: Idarucizumab (Praxbind) 5 g IV; if unavailable, FEIBA 50–80 μ/kg; if unavailable, use a three- or four-factor PCC at 25–50 μ/kg. If using three-factor PCC, consider supplementation with FFP for factor VII. Tranexamic acid (TXA) may be considered. Hemodialysis has been shown to remove active dabigatran from circulation.

Apixaban, betrixaban , edoxaban, and rivaroxaban: If emergent surgery is required, andexanet alfa may be given. Low dose (for those who received rivaroxaban <10 mg, apixaban <5 mg, or >8 h since last dose of factor Xa inhibitor) is a bolus 400 mg at rate of 30 mg/min followed by infusion of 480 mg at rate of 4 mg/min. High dose (for those who are on rivaroxaban >10 mg, apixaban >5 mg, or dose unknown or <8 h since last dose of factor Xa inhibitor) is bolus of 800 mg at 30 mg/min followed by infusion of 960 mg at a rate of 8 mg/min. If andexanet alfa not available, four-factor PCC.

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Cusack, T.J., Ziai, W. (2022). Intracerebral Hemorrhage (ICH) Approach: Bedside Practical Review. In: Rodríguez, C.N., et al. Neurosonology in Critical Care . Springer, Cham. https://doi.org/10.1007/978-3-030-81419-9_3

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