Intracerebral hemorrhage treatment

Antiseizure drugs that induce CYPs are associated with vitamin K deficiency in the newborn, possibly resulting in coagulopathy and intracerebral hemorrhage. Treatment of the mother with vitamin Kj, 10 mg/day during the last 2-4 weeks of gestation, has been recommended for prophylaxis. 

The REACH system in southern Georgia (United States) and the TEMPiS system in Germany reported decreased latency to rt-PA delivery on a larger scale. REACH system investigators reported 194 acute stroke consultations dehvered via telemedicine. The time from symptom onset to rt-PA delivery decreased from 143 minutes in the first 10 patients treated to 111 minutes in last 20 patients of 30 patients treated with rt-PA, 23% were treated in 90 minutes or less and 60% were treated within 2 hours without any incidence of post-treatment symptomatic intracerebral hemorrhage. In 2004, the second year of the TEMPiS system, 115 patients in telemedicine-networked community hospitals and 110 patients in stroke centers received rt-PA for acute ischemic stroke or TIA. Patients treated at networked community... 

There is no proven treatment for intracerebral hemorrhage. Management is based on neurointensive care treatment and prevention of complications. Oral nimodipine is recommended in subarachnoid hemorrhage to prevent delayed cerebral ischemia. 

Intracerebral Hemorrhage Trial compared three different doses and placebo. Doses were 40,80, or 160 mcg/kg or placebo given as an IV infusion over 1 to 2 minutes within 4 hours after the onset of symptoms. Hematoma growth was decreased at 24 hours, mortality was decreased at 90 days, and overall functioning was increased at 90 days. Further studies are ongoing to evaluate the role of recombinant factor Vila in ICH treatment.41... 

Anticoagulants are sometimes used in the overall treatment of PVE even though there are risks of intracerebral hemorrhage or hemorrhagic infarction. Countering this risk, however, is the risk of major thromboembolic complications involving the central nervous system that may occur in die absence of continued anticoagulant therapy. 

Typically, patients with confirmed CVST are treated with intravenous heparin even in the presence of intracerebral hemorrhage. Although there is only one placebo-controlled, double-blind study showing a significant advantage of intravenous dose-adjusted unfractionated heparin therapy in patients with CVST (Einhaupl et al. 1991), heparin as the first-line treatment is recommended because of its efficacy, safety and feasibility (Ameri and Bousser 1992 Bousser 1999). Only in rare cases may fibrinolytic therapy or thrombectomy be considered as alternative treatment options. 

Some of the association between atrial fibrillation and stroke must be coincidental because atrial fibrillation can be caused by coronary and hypertensive heart disease, both of which may be associated with atheromatous disease or primary intracerebral hemorrhage. Although anticoagulation markedly reduces the risk of first or recurrent stroke, this is not necessarily evidence for causality because this treatment may be working in other ways, such as by inhibiting artery-to-artery embolism, although trials of warfarin in secondary prevention of stroke in sinus rhythm have shown no benefit over aspirin (Ch. 24). 

Brain imaging is required to distinguish between primary intracerebral hemorrhage and cerebral infarction since this distinction cannot be made reliably on clinical criteria alone (Hawkins et al. 1995). Recent developments in brain imaging, in particular new MRI sequences, and to a lesser extent CT techniques, have enabled visualization of the pathophysiological processes involved in brain infarction. These new techniques are being developed to select patients suitable for thrombolytic treatment beyond the three-hour time window (Ch. 21) and may in the future enable targeting of treatments such as neuroprotection. 

So far predictive models only apply to a small proportion of patients and are not sufficiently accurate to inform treatment decisions in routine clinical practice. The various subtypes of ischemic stroke have very different outcomes patients with total anterior circulation infarction (TACI) have just as poor an outcome as those with primary intracerebral hemorrhage (Table 16.1). The best single predictor of early death is impaired consciousness, but many other predictors of survival have been identified (Table 16.2). Many of these variables are inter-related, but prognostic models based on independent variables do not provide much more information than an experienced clinician s estimate (Counsell and Dennis 2001 Counsell et al. 2002). 

Chapter 22 Specific treatment of acute intracerebral hemorrhage... 

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