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Spontaneous intracerebral hemorrhage: Treatment and prognosis

INTRODUCTION

Intracerebral hemorrhage (ICH) is the second most common cause of stroke, following ischemic stroke. Mortality and morbidity is high. Initial goals of treatment include preventing hemorrhage extension, as well as the prevention and management of elevated intracranial pressure along with other neurologic and medical complications.

The treatment and prognosis of spontaneous intracerebral hemorrhage will be reviewed here. Other aspects of ICH are discussed separately. (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis".)

INITIAL TREATMENT

Management of intracerebral hemorrhage (ICH) includes both medical and surgical interventions [1,2].

General management issues — Guidelines from the American Heart Association/American Stroke Association (AHA/ASA) recommend that patients with ICH receive monitoring and management in an intensive care unit [1,3]. This recommendation is based upon the frequent association of ICH with elevations in intracranial pressure and blood pressure, the need for intubation and mechanical ventilation, and multiple medical issues and complications. Many neurologic as well as medical complications that require urgent intervention occur subsequent to the initial evaluation [4]. Ideally, acute neurosurgical care should be available at the hospital in which patients are cared for [5]. In addition, there is some evidence that intensive monitoring and stroke unit care is associated with improved outcomes in patients with acute stroke [6,7].

Early DNR orders or limitations to care are not always inappropriate after ICH; the difficulty lies in deciding when such limitations are indeed the most appropriate approach [8]. Because prognostication for individual patients with acute ICH is an uncertain science, current guidelines suggest careful consideration of aggressive, full care during the first 24 hours after ICH onset and postponement of new DNR orders during that time [1,3]. This recommendation does not apply to patients with preexisting DNR orders. (See 'Prognosis' below.)

                          

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Literature review current through: Oct 2014. | This topic last updated: May 21, 2014.
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