Cerebral Hemorrhage: Therapy

Suspicion of intracerebral hemorrhage: call 911 immediately! (Call 112)

General measures

• Nicotine restriction (refraining from tobacco use).
• Limited alcohol consumption (men: max. 25 g alcohol per day; women: max. 12 g alcohol per day).
• Aim for normal weight! Determination of BMI (body mass index, body mass index) or body composition by means of electrical impedance analysis and, if necessary, participation in a medically supervised weight loss program.
  • BMI ≥ 25 → participation in a medically supervised weight loss program.
• Review of permanent medication due topossible effect on the existing disease.
  • Anticoagulants
    • Coumarins (phenprocoumon* (product names: Marcumar, Falithrom); warfarin (product names: Coumadin, Marevan); acenocoumarol (product name: Sintrom).
    • Direct inhibitors of thrombin (Argatroban, Lepirudin).
    • Heparin analogues (fondaparinux).
    • Heparins (certoparin, dalteparin, enoxaparin, nadroparin, reviparin, tinzaparin).
    • Heparinoids (danaparoid
    • New oral anticoagulants (NOAK; NOAC; direct oral anticoagulants, DOAK).
      • Direct factor Xa inhibitor (apixaban, edoxaban, rivaroxaban).
      • Direct and selective factor Xa inhibitor (apixaban).
      • Selective thrombin inhibitor (dabigatran); antidote: idarucizumab can reverse the effect of the oral anticoagulant dabigatran within minutes; bleeding stops within 2.5 hours-but there may be a rebound in bleeding times after 12 to 24 hours, leading to rebleeding in some patients.
    • Antiplatelet agents (abciximab, acetylsalicylic acid (ASA), combination of acetylsalicylic acid and dipyridamole, clopidogrel, eptifibatide, ilomedin (prostacyclin analog), prasugrel, ticagrelor, ticlopidine, tirofiban)Low-dose (up to 300 mg/day) continuous medication with acetylsalicylic acid (ASA; Antiplatelet agents), as prescribed in the primary and secondary prevention of vascular events, does not increase the risk of intracranial hemorrhage.
  • Fibrinolytics (drugs used for the acute treatment of conditions caused by vascular occlusion; they cause the blood clot to dissolve).

Stroke Unit – for small intracerebral hemorrhage

The patient should be observed in a stroke unit. Blood pressure must be controlled and hemorrhage progression (progression of cerebral hemorrhage) prevented.The following values are monitored there:

• Respiration
• Blood pressure
• Heart rate
• Glucose (blood sugar)
• Electrolytes
• Blood clotting
• Body temperature

Supportive therapy – for large intracerebral hemorrhage

Airway management (ventilation)

• Pulse oximetry-measured oxygen saturation (SpO2) should be >90%.
• Patients with severe sepsis/septic shock should be ventilated early.
• The following parameters should be maintained:Controlled ventilation:
  • Tidal volume (breath volume, or AZV; is the set volume applied per breath): 6 ml/kg standard body weight
  • Plateau pressure (measure of end-inspiratory pressure in alveoli in a flow-free phase): < 30 cm H2O.
  • Oxygen saturation (SpO2): > 90%.
• PEEP (engl. : positive end-expiratory pressure; positive end-expiratory pressure) as a function of FiO2 (indicates how high the O2 content in the breathing air is).
• In severe oxygenation disorders, prone positioning or 135° positioning should be performed.
• Weaning (English : to wean; or ventilator weaning is the phase of weaning a ventilated patient from the ventilator) should be started as soon as possible.

The following additional therapeutic measures may be considered:

• If the affected person permanently takes anticoagulants/anticoagulants → coagulation compensation (see below “Drug therapy/pharmacotherapy”).
• If occlusive hydrocephalus (hydrocephalus occlusus; pathological/diseased dilatation of the fluid-filled fluid spaces (cerebral ventricles) of the brain) is present → installation of a ventricular drainage device (EVD) (see “Surgical therapy” below)
• Possibly hematomevacuation (hematoma evacuation) (see “Surgical therapy” below).
• Cerebral pressure-lowering measures (see “Drug therapy/pharmacotherapy” below).

Physical therapy (incl. physiotherapy)

• For prophylaxis of thromboembolic complications: elastic stockings and intermittent pneumatic compression.

Rehabilitation

• Early rehabilitation (begins after a few days) – consisting of:
  • Physiotherapy
  • Speech therapy
  • Occupational therapy