intracranial hemorrhage
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Etiology
- risk factors (see intracerebral hemorrhage)
Radiology
Complications
Management
reversal of anticoagulation
- vitamin K antagonists should be reversed[4]
- suggested dosing is 10 mg vitamin K intravenously
- repeat if INR > 1.4 at 24-48 hours
- for patients with INR > 1.4, administering 3- or 4-factor prothrombin complex concentrate better than fresh frozen plasma
- oral direct factor Xa inhibitors
- if event occurred within 3-5 1/2 lives of drug administration, 4-factor prothrombin complex or
- andexanet alfa for reversal of apixaban anticoagulation[1]
- if event occurred within 3-5 1/2 lives of drug administration, 4-factor prothrombin complex or
- dabigatran
- reverse with idarucizumab (Praxbind)
- if not available, use 4-factor prothrombin complex concentrate
- therapeutic intravenous heparin
- low-molecular-weight heparin
- thrombolytic therapy
- cryoprecipitate should be administered
- antiplatelet agents
- platelet transfusions not recommended, unless neurosurgery needed[4]
- resuming anticoagulation after intracranial hemorrhage
- anticoagulation can be resumed safely in most patients
- 10% of patients resuming anticoagulation will have a recurrence of intracranial hemorrhage, some fatal[2]
systolic blood pressure control
- target systolic blood pressure 140-160 mm Hg[5] or mean arterial pressure = 110 mm Hg[1]
- preferred antihypertensive agents
apparently, low dose aspirin may be continued[5]
anticonvulsants not indicated in to absence of seizure or epileptiform activity on EEG[5]
desmopressin associated with less hemorrhage expansion in antiplatelet- associated hemorrhage but no change in clinical outcome[6]
More general terms
More specific terms
References
- ↑ 1.0 1.1 1.2 1.3 Medical Knowledge Self Assessment Program (MKSAP) 16,18, 19. American College of Physicians, Philadelphia 2012, 2018, 2021
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 2.0 2.1 Poli D et al. Recurrence of ICH after resumption of anticoagulation with VK antagonists: CHIRONE Study. Neurology 2014 Feb 21; <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/24562060 <Internet> http://www.neurology.org/content/early/2014/02/21/WNL.0000000000000245
- ↑ Shin JY, Park MJ, Lee SH et al Risk of intracranial haemorrhage in antidepressant users with concurrent use of non-steroidal anti-inflammatory drugs: nationwide propensity score matched study. BMJ 2015;351:h3517 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/26173947 <Internet> http://www.bmj.com/content/351/bmj.h3517
Mercer SW et al Risk of intracranial haemorrhage linked to co-treatment with antidepressants and NSAIDs. BMJ 2015;351:h3745 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/26173949 <Internet> http://www.bmj.com/content/351/bmj.h3745 - ↑ 4.0 4.1 4.2 Kritek P. New Guidelines on Reversal of Anticoagulants in Patients with Intracranial Hemorrhage. NEJM Journal Watch. Jan 17, 2017 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Frontera JA, Lewin JJ 3rd, Rabinstein AA et al. Guideline for reversal of antithrombotics in intracranial hemorrhage: Executive summary. A statement for healthcare professionals from the Neurocritical Care Society and the Society of Critical Care Medicine. Crit Care Med 2016 Dec; 44:2251 PMID: https://pubmed.ncbi.nlm.nih.gov/27858808 - ↑ 5.0 5.1 5.2 5.3 Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
- ↑ 6.0 6.1 Feldman EA, Meola G, Zyck S et al. Retrospective assessment of desmopressin effectiveness and safety in patients with antiplatelet-associated intracranial hemorrhage. Crit Care Med 2019 Sep 24; PMID: https://pubmed.ncbi.nlm.nih.gov/31567345
- ↑ Chaudhary R, Singh A, Chaudhary R, et al. Evaluation of direct oral anticoagulant reversal agents in intracranial hemorrhage: a systematic review and meta-analysis. JAMA Netw Open. 2022;5:e2240145. PMID: https://pubmed.ncbi.nlm.nih.gov/36331504