Step 6: Consider cerebral angiography

•Angiography is not recommended in elderly patients with hypertension and who have hemorrhage in typical territories such as basal ganglia, thalamus, cerebellum, or brain stem and in whom CT scan shows no suggestion of a structural lesion.

•However, if the patient is young, normotensive with no definite cause of hemorrhage, an angiogram would be recommended especially if he/she is a candidate for surgical intervention.

Step 7: Consider surgical management

•In most patients, benefits of surgery are debatable unless:

–They have cerebellar hemorrhage and are deteriorating.

–They have brain stem compression and/or hydrocephalus.

–There is intraventricular bleed or hydrocephalus requiring external ventricular drain.

–There is lobar clot of more than 30 mL located within 1 cm of the cortical surface.

–Decompressive craniectomy may be considered in some patients who are young with involvement of nondominant hemisphere.

Step 8: General care

•Deep vein thrombosis prophylaxis with mechanical compression device should be started at the earliest in ICH and low molecular weight heparin or UFH in cerebral infarct.

•Antiulcer prophylaxis should be started with H2 blocker.

•Proper skin and eye care should be provided.

•Aspiration precaution should be taken.

•Proper nutrition should be provided.

•Bowel and bladder functions should be taken care of.

•Contractures should be prevented by supervised physiotherapy.

•Fever and glycemic control should be properly managed.

Suggested Reading

1.The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–7.

A randomized, double-blind trial of intravenous recombinant tPA for ischemic stroke. Despite an increased incidence of symptomatic intracerebral hemorrhage, treatment with intravenous tPA within 3 h of the onset of ischemic stroke improved clinical outcome at 3 months.

As compared with placebo, intravenous alteplase administered between 3 and 4.5 h after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke; alteplase was more frequently associated with symptomatic intracranial hemorrhage.

Early intensive BP-lowering treatment is clinically feasible, well tolerated, and seems to reduce hematoma growth in ICH.

2.Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655–711.

A comprehensive guideline on management of ischemic stroke.

3.Morgenstern LB, Hemphill JC 3rd, American Heart Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2010;41(9):2108.

A comprehensive guideline on management of cerebral hemorrhage.

Websites

1.aic.cuhk.edu.hk

Neurological teaching site for ICU residents

2.Stroke.ahajournals.org

Journal on cerebrovascular diseases published by American Heart Association

3.library.med.utah.edu/neurologicexam

A comprehensive site for neurological examination

4.med.harvard.edu

A comprehensive atlas of brain imaging