Spontaneous ICH

Spontaneous Intracranial Hemorrhage (ICH) is one of the more common things we see in the Neuro ICU. This is most commonly caused by hypertension, and so blood pressure management is usually a key part of ICU care in these patients. There is a fine line to walk between proper brain perfusion and increasing further bleeding. The other major pharmacological question involves reversal of oral anticoagulants that the patient may be taking. Although it’s not usually the cause of the bleed (again, hypertension, possibly in concern with anticoagulants is most likely; other causes include aneurysm rupture, vascular malformation, and malignancy), they can certainly exacerbate the bleeding.

@emergencymeded has a great post on Instagram covering the basics of pharmacological management of these patients. They point out that BP targets are controversial. I think controversial may be too strong, the guidelines generally recommend SBP < 140, but they do point out 2 large trials, INTERACT II and ATACH 2 both suggest that there is no increase in negative outcomes by allowing SBP up to 180. For management, labetalol and nicardipine are the mainstays of therapy. I generally start with 10-20mg labetalol IVP q1h PRN. If that is insufficient or if there are contraindications to beta blocker therapy, you can add 10-20mg hydralazine IVP q1h PRN (although this is rarely sufficient). If you’re still not able to get good control, or if you’re having to give lots of PRNs, a nicardipine gtt is the next best step. Although, be aware that due to it’s longer half-life, nicardipine isn’t really truly titratable. Once you get BP in range, it’s a good idea to back off a little on the dose to avoid overshooting. Clevidipine is probably a better option, but it’s pretty expensive so not as readily available. With a half-life of around 1 min, clevidipine is a truly titratable drug. Be aware that it is a lipid emulsion and can easily be confused with propofol in intubated patients.

When it comes to reversing oral anticoagulation drugs, the first question to ask is, “should we reverse?” Patients are on these drugs for a reason, after all. This is a decision that needs to be made after a careful risk:benefit assessment. In most cases though, you’ll end up reversing these drugs to prevent worsening of the bleed. There are 2 different strategies to reverse these drugs, targeted and non-targeted. Targeted involves giving an “antidote,” that is a specific reversal agent. Vitamin K for warfarin (although it doesn’t work fast enough and you’ll want to give FFP or 4-PCC as well), idarucizamab for dabigitran, and andexanet for the Xa inhibitors. Andexanet is not widely available due to cost and questions of efficacy. Non-targeted involves giving clotting factors that reverse all drugs. This is predominately 4-factor prothrombin complex concentrate (4-PCC) as FFP won’t reverse the Xa inhibitors and 4-PCC has been shown to do a better job of reversing warfarin than FFP. I’ll do a whole post soon on reversing anti-coagulation drugs.