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intracranial hemorrhage

Etiology: - risk factors (see intracerebral hemorrhage) Radiology: - CT of the head vs MRI - less expensive, faster, more available [1] 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 concentrate should be used - dabigatran - reverse with idarucizumab (Praxbind) - if not available, use 4-factor prothrombin complex concentrate - therapeutic intravenous heparin - IV protamine at 1 mg for every 100 units of heparin administered in the past 2-3 hours (maximum dose, 50 mg) - low-molecular-weight heparin - protamine - 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 - nicardipine - labetolol 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]

Interactions

disease interactions

Specific

cephalohematoma cerebral laceration cerebrovascular hemorrhage intracranial hematoma

General

head injury internal hemorrhage

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16,18, 19. American College of Physicians, Philadelphia 2012, 2018, 2021
  2. Poli D et al. Recurrence of ICH after resumption of anticoagulation with VK antagonists: CHIRONE Study. Neurology 2014 Feb 21; PMID: 24562060 http://www.neurology.org/content/early/2014/02/21/WNL.0000000000000245
  3. 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 PMID: 26173947 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 PMID: 26173949 http://www.bmj.com/content/351/bmj.h3745
  4. 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: 27858808
  5. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  6. 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: 31567345

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