Treatment of intracerebral hemorrhage: From specific interventions to bundles of care

Abstract

Intracerebral hemorrhage (ICH) represents a major, global, unmet health need with few treatments. A significant minority of ICH patients present taking an anticoagulant; both vitamin-K antagonists and increasingly direct oral anticoagulants. Anticoagulants are associated with an increased risk of hematoma expansion, and rapid reversal reduces this risk and may improve outcome. Vitamin-K antagonists are reversed with prothrombin complex concentrate, dabigatran with idarucizumab, and anti-Xa agents with PCC or andexanet alfa, where available. Blood pressure lowering may reduce hematoma growth and improve clinical outcomes and careful (avoiding reductions ≥60 mm Hg within 1 h), targeted (as low as 120-130 mm Hg), and sustained (minimizing variability) treatment during the first 24 h may be optimal for achieving better functional outcomes in mild-to-moderate severity acute ICH. Surgery for ICH may include hematoma evacuation and external ventricular drainage to treat hydrocephalus. No large, well-conducted phase III trial of surgery in ICH has so far shown overall benefit, but meta-analyses report an increased likelihood of good functional outcome and lower risk of death with surgery, compared to medical treatment only. Expert supportive care on a stroke unit or critical care unit improves outcomes. Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24-48 h of care. Implementation of acute ICH care can be challenging, and using a care bundle approach, with regular monitoring of data and improvement of care processes can ensure consistent and optimal care for all patients.

Keywords: Intracerebral hemorrhage; anticoagulants; antiplatelet drugs; blood pressure; care bundles; critical care; neurosurgery.

Figure 1.

Cubic spline (blue line) and linear spline (black line) regression analyses showing the relationship of hematoma reduction (EOT ICH Volume) to the probability of having a good outcome (green dots), mRS 0–3, (vs. a poor outcome – red dots) at one year. Clot volume reduction beyond the 15 mL goal increased the chances of improved functional outcome by 10% for each additional milliliter removed (p = 0.002). Reprinted from Awad et al., Surgical performance determines functional outcome benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure, Neurosurgery 2019; 84: 1157–1168, by permission of the Congress of Neurological Surgeons.

Figure 2.

Run chart demonstrating progress in reducing the needle-to-target (NTT) time for intensive BP lowering in ICH before, during and after implementation of the ABC care bundle at Salford Royal Hospital, UK. The process target of 60 min is shown by a dashed horizontal line. Each point is the mean NTT for the month when BP lowering was attempted with parenteral medication. Publication of INTERACT2 did not alter management until a standardized protocol was introduced at bundle implementation. Further gains were achieved on switching to glyceryl trinitrate as the first-line drug.