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Episode 94: INSIGHTS - Intracerebral Haemorrhage

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Listen to the fifth episode of NCS' INSIGHTS series, this time on Intracerebral Hemorrhage.

The INSIGHTS series is hosted by Casey Albin, MD and Salia Farrokh, PharmD, and covers different topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource to offer content exclusively dedicated to the practice of neurocritical care. Learn more about ON CALL®.

This episode is sponsored by ceribell.

Time is brain when it comes to seizures. Ceribell Point of Care EEG empowers the bedside team to detect or rule out seizure activity in minutes. To learn more, visit

The NCS Podcast is the official podcast of the Neurocritical Care Society.


  • Salia Farrokh, Pharm.D., BCPS, BCCCP

    Salia Farrokh, PharmD, BCPS, BCCCP is a neuro ICU clinical pharmacist specialist at Johns Hopkins Hospital. Dr. Farrokh received her PharmD degree from Saint John Fisher College, Wegmans School of Pharmacy in Rochester, NY. Her postgraduate training includes residencies in Critical Care and Pharmacy Practice at Yale-New Haven Hospital. Dr. Farrokh’s research interests include effective antiplatelet therapy in neuro intervention patients, optimal pain management in neuro ICU patients, and use of neurostimulants in this setting. Dr. Farrokh is passionate about training and precepting students and residents and is a certified ENLS trainer.

  • Casey Albin, MD

    Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/BWH/MGH. She completed Neurocritical Care fellowship at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of a best-selling textbook The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, blogs, and podcasts. She serves on the Education Committee of the Neurocritical Care Foundation.

  1. All right, guys, welcome back. This
  2. is the Insights Podcast from Neuro
  3. Critical Care Society. As a reminder,
  4. the Insights Podcast is based on the
  5. on-call content, which is published
  6. online. It's a continually updated
  7. textbook with experts in the field
  8. reviewing all of the latest guidelines
  9. and up-to-date literature, and so we
  10. really invite you to check this out,
  11. but we are very, very thankful for our
  12. sponsors, Biogen and Cerebell, and now
  13. a word from our sponsor Time is brain
  14. when it comes to seizures. Cerebell
  15. Point of Care EEG empowers the bedside
  16. team to detect or rule out seizure
  17. activity in minutes. To learn more,
  18. visit Cerebellcom. All right, well,
  19. welcome back, Celia. It's been a while.
  20. Yeah, thanks for having me. Thanks for
  21. being here. This has been great. I'm
  22. happy to be back and do all of this
  23. again and have so much fun with
  24. neurocritical care. Love it So we left
  25. off when we were doing a date. a very,
  26. you know, core topic in neurocritical
  27. care, which is the management of acute
  28. ischemic stroke. And today, we're
  29. going to flip to the other side of the
  30. stroke coin, the sort of hemorrhagic
  31. stroke, and kind of go through, you
  32. know, the clinical approach to when
  33. this patient walks in the door. And so
  34. what I really want to emphasize in sort
  35. of starting out from the clinical
  36. perspective is that it is impossible to
  37. tell if a patient is having an ischemic
  38. stroke or hemorrhagic stroke just by
  39. looking at the patient. There's been a
  40. lot of effort to see, you know, is
  41. there, are there some more telltale
  42. signs like, are this, you know,
  43. intercrenal hemorrhage patients, are
  44. they more hypertensive? Are they
  45. sleepier? And while that might be true
  46. in some cases, it's not reliable. So
  47. again, this patient, like, just as
  48. you do for any ischemic stroke alert,
  49. the same principles apply for
  50. hemorrhagic stroke. And that's when you
  51. notice that a patient has Bocal deficit
  52. that you can localize. to one lobe of
  53. the hemispheres or the cerebellum, you
  54. really need to get, or brainstem, you
  55. really need to get that patient to the
  56. CT scanner to figure out if they are
  57. having an ischemic event and then
  58. qualify for all the therapy we talked
  59. about in the last two episodes, or if
  60. this is an ICH. And once you make that
  61. determination, then it becomes kind of
  62. an algorithm for the management of these
  63. patients upfront, the big focus being
  64. ABCs, which for these patients,
  65. obviously the airway and the breathing.
  66. But then we're thinking a lot about the
  67. circulation. And then that, I mean,
  68. they're blood pressure. And so Celia,
  69. I was wondering, since blood pressure
  70. control is really the mainstay of
  71. treatment for these patients, what are
  72. some clinical tips to take for the
  73. bedside when you're thinking about, how
  74. do I lower the blood pressure? How much
  75. do I lower the blood pressure? What
  76. agent is best for lowering the blood
  77. pressure? Since that's such a big
  78. decision for this patient population Um,
  79. There's a lot of debate, probably about
  80. what is the right target, and we can
  81. talk about that. I think before we get
  82. there, the new guidelines, the 2022
  83. ICH guidelines, talk about the fact
  84. that the sooner the better, and they
  85. specifically talk about that within two
  86. hours of ICH really want to get on the
  87. blood pressure control, and the idea is
  88. that you get them within the goal, then
  89. the first hour of starting your
  90. anti-hypertensive medication Now, what
  91. goal do we have in mind? I think not to
  92. go over all the details, but we have we
  93. had the ATAC trial and the Interact
  94. trial. I think there was a lot of
  95. debate Do. you do less than 180? Do
  96. you do less than 140? Guess what? The
  97. guidelines say 130 to 150 now. So I
  98. think 140 is what we typically kind of
  99. think about. And you know, there is
  100. also some discussion that in patients
  101. with mild to moderate ICH, getting the
  102. blood pressure less than 130 is going to
  103. be harmful it's just something to keep
  104. in mind. 130 to 150 is the goal. If
  105. they come in with blood pressure within
  106. 150 to 220, I think it's a little bit
  107. more gray when people come in with blood
  108. pressure, more than 220, I think
  109. that's when we talk about do we do
  110. percentage reduction 10 to 15 from that
  111. initial presentation? You already know.
  112. But I think and patients are massive. I
  113. see it's again, like the evidence is
  114. gray. They don't have specific
  115. recommendations for the target. A lot
  116. of these patients have to go for
  117. surgical interventions and all that. So
  118. this is mostly for mild and moderate,
  119. ICH. Again, they don't come in with
  120. blood pressure of over 220. The target
  121. is 130 to 150. And don't get them below
  122. the 130 because that's harmful.
  123. And the next question is, okay, what
  124. agent do you use? I think just like
  125. anything in critical care, the basic of
  126. critical care I think management is that
  127. you want an agent that works really fast,
  128. that can be given IV and that also is
  129. easily titrateable, right? You don't
  130. want to give a drug that stays in the
  131. system forever and you can't really
  132. titrate or it's not quick onset. And
  133. based on that, I think the agents that
  134. come into mind, the agents that
  135. typically are used are
  136. IV neckardipine, which is quick onset,
  137. you know, it's easily titrateable.
  138. It's a calcium channel blocker. Another
  139. calcium channel blocker that some
  140. institutions may have is clovidipine.
  141. It's also quick on, actually quicker on,
  142. quicker off, that may be something that
  143. is nice about it, but it's expensive.
  144. Not a lot of institutions have that.
  145. And honestly, there are some
  146. retrospective reviews that look at these
  147. two agents and there is no difference in
  148. outcomes when they look at ICH expansion
  149. So if you don't have a clove at a pain,
  150. do not worry. And that cardopene is
  151. probably as great and it does the job.
  152. Um, what are the other agents, um,
  153. think IV, asthma, if your patient's
  154. heart rate can tolerate that because,
  155. you know, it is used for cerebral
  156. pressure, but it is a, uh, beta
  157. blocker and it can drop, um, heart
  158. rate to some degree. It's something to
  159. keep in mind. I'd be a libadol. If you
  160. don't have the capacity to do an
  161. infusion and you just need to use
  162. interim endoses, I'd be a libadol as a
  163. good option. Um, lastly, I kind of
  164. wanted to mention that although we talk
  165. about IV hydralisine, this is probably
  166. not the preferred agent end of studying
  167. You really don't want to use it unless
  168. you absolutely are out of all the other
  169. options, just because it is more
  170. unpredictable as far as the onset and
  171. the outcomes and the blood pressure
  172. management. So that's usually a last
  173. resort. And then something to also
  174. highlight is that you absolutely don't
  175. want to use your nitrates into studying
  176. agents and they can possibly increase
  177. ICP. I love that. I mean, I just
  178. would echo. I feel like hydralisine has
  179. such a, just really unpredictable
  180. effect and for some patients it drops
  181. them. much and others it doesn't do
  182. anything. The other thing I would say
  183. for these patients is if you have the
  184. capacity at your shop to put in an
  185. A-line that's really helpful you know
  186. most places you can give an A-line in
  187. really quickly and that allows for like
  188. the continual monitoring of this it
  189. makes it easier for the nurses to
  190. titrate this consistently you know we're
  191. not having big swings from you know
  192. taking the blood pressure really high
  193. and then dropping it too low then
  194. turning off the infusion and the blood
  195. pressure rises you know we want to have
  196. a controlled downslope to that target of
  197. 130 to 150 if your patient is presenting
  198. with a blood pressure less than 220. I
  199. got to tell you like a lot of patients
  200. where I work coming with blood pressures
  201. way higher than 220 and for them we're
  202. doing exactly what Sally was saying
  203. which is just a percentage reduction so
  204. usually getting them down to like less
  205. than 180 less than 160 70 again because
  206. we're gonna harm their kidneys if they
  207. are just chronically useful. to seeing
  208. a very high blood pressure. And then we
  209. just box their kidneys. That leads to
  210. all sorts of like downstream
  211. consequences with sort of the AKI.
  212. And then you have to figure out this
  213. person and I populate it, right?
  214. Because the other thing that we can do
  215. to limit secondary brain injury is make
  216. sure that we are reversing any
  217. quagulopathy. So this gets tricky, so
  218. I'll walk us through one of the
  219. guidelines, say, how am I going to
  220. even determine if the patient's on a doe
  221. act if there's not family around? This
  222. gets kind of complicated
  223. If you're right on, it's very
  224. complicated. I think a few maybe
  225. principles to think about, and then
  226. hopefully that can help us. I think
  227. number one is that if you have any
  228. suspicion that this patient's on
  229. anti-regulation, do not wait for any
  230. levels to come back before reversing
  231. them. This is true for everything, for
  232. a boyfriend, doe acts, all the things,
  233. and we'll go through the specifics of
  234. all of that if you know when they take
  235. it that's amazing and you can figure out
  236. when was the last dose and think about
  237. did they even you know qualify to be
  238. reversed. So now walking through how we
  239. decide where do we go from here again I
  240. think for the majority of these agents
  241. something that I keep talking about in
  242. teaching in our unit is that I go by the
  243. rule of 48 hour mark meaning 48 hours
  244. pretty safe to think about these
  245. patients should be reversed. Again I
  246. think this is a multidisciplinary
  247. discussion but I think for the majority
  248. of agents 48 hours is probably a good
  249. time frame to have in mind and that's
  250. really based on three to five half lives
  251. of these drugs given that the half life
  252. ranges from 10 to 12 hours for the
  253. majority of these agents again in a
  254. patient with normal renal function.
  255. I wanted to kind of walk us through
  256. individual agents, so let's start with
  257. Warfarin maybe. Again, we don't see
  258. Warfarin as much as we used to, which
  259. is nice, but I think there's a time
  260. that evidence really kind of suggests
  261. that you have to wait for INR to come
  262. back before you reverse people. There
  263. is plenty of literature now talking
  264. about fixed dosing of four factor PCC,
  265. meaning for IC agencies cases, you can
  266. just give a fixed dose and you don't
  267. really have to worry about these people,
  268. the INR coming back to reverse that.
  269. Now, the target INR is less than 14,
  270. so if you're INR still above 14 after
  271. that fixed dose and you're still
  272. concerned, you can think about a
  273. supplemental dose. Again, this could
  274. be a discussion with the team based on
  275. risk factors and everything else. So
  276. again, no need to wait for INR. You
  277. have that capability to do a fixed dose
  278. four factor PCC. Now, what about
  279. Heparin or Lobenox, Prodomenis, the
  280. agent of choice? I think that one's a
  281. little bit easier. just because a lot
  282. of people are familiar with that. And
  283. then we get to the 10A inhibitors,
  284. right? It picks a band, right rocks a
  285. band, docks a band, all those fun
  286. agents that we see more and more these
  287. days. So this is where I think it gets
  288. controversial. And I think this is
  289. controversial.
  290. So much controversy. So I can, again,
  291. I think because the evidence isn't there,
  292. I'll tell you what I have seen from
  293. evidence and what we do and all of that
  294. But again, very controversial, just
  295. like Casey said, I think you can talk
  296. to 10 people in one room and everyone
  297. will give you a different answer. I
  298. think the evidence, though, is that we
  299. do not have any head-to-head trials
  300. looking at these two agents, K-Central,
  301. which is four-factor PCC and index in it,
  302. in the same population, the same kind
  303. of randomized trial. And there is some
  304. hope that even ongoing trial that is
  305. gonna get published soon and hopefully
  306. that will answer some of those questions.
  307. But we don't have anything yet. Now,
  308. some institutions have looked at their
  309. experience, meaning they looked at case
  310. center alone and they looked at indexing
  311. it alone. And they published their
  312. outcomes. And guess what? What we know
  313. from these, again, retrospective. So
  314. we have to think about that. What we
  315. know is that the efficacy is probably
  316. comparable. Again, I say probably
  317. because they look at different
  318. definitions of ICH hemostasis. They had
  319. different patient populations and all of
  320. that. And it was not randomized and all
  321. of that But then one thing that also we
  322. found out was that quesentra was
  323. associated with a lower risk of
  324. thrombosis. So as of now, the
  325. retrospective studies that are published,
  326. again, retrospective, that's the key
  327. here, they saw thrombosis of around 4
  328. to 5. And then fixed ICH was a big
  329. study that came from the neurocrotable
  330. care society. And then for the index
  331. and the index of thrombosis, or
  332. actually reported a higher rate, about
  333. 10 risk of thrombosis. So that's just
  334. something to keep in mind. I think to
  335. me, whatever you have in your
  336. institution that is faster, you have a
  337. protocol for it, you know that you can
  338. activate that process and you can get
  339. the approval and you can get that
  340. situation and that ball rolling fast,
  341. that's what I would do. And one
  342. piece of information to also share is
  343. that people ask about, okay, you are
  344. saying that do not send for any levels
  345. before reversing people. I still to
  346. this date, I believe in that, if your
  347. suspicion is high, you don't want to
  348. send 10A levels, you don't want to send
  349. INR, any of that. People ask about
  350. what about, especially with indexing,
  351. if you send 10A levels after, you
  352. really should not. The idea is that,
  353. you know, in the annex of four, they
  354. actually had calibrated 10A levels for
  355. the agent that they were looking at So
  356. it picks a band, right rocks a band,
  357. all of that. And a lot of institutions
  358. don't have that. And even an exophore
  359. showed that majority of people's 10A and
  360. I'm sorry, levels got reduced, but not
  361. everyone's level got reduced. So the
  362. idea was that if you achieve hemostasis
  363. with your ICH and that's confirmed,
  364. then you're done. Totally, I think
  365. that's such great advice. Give whatever
  366. is available fastest, right? If that's
  367. four factor PCC, just give that. You
  368. know, the dosing for that, sort of we
  369. are using 25 to 50 international units
  370. for KG. Sally, is that what y'all are
  371. using as well? Are we talking about
  372. Warfarin Reversal or DOAC reversal?
  373. Sorry, for DOAC reversal. So we
  374. actually have a fixed dosing now, which
  375. is making it really easy. So for
  376. Warfarin Reversal, we have 1, 500
  377. units. And for based on body weight,
  378. obviously, it's a little bit more
  379. complicated than that, meaning there's
  380. a threshold of body weight below and
  381. above, but 1, 500 is universally what
  382. we eat for typical average people. And
  383. then for DOA Act related, ICA for use
  384. 2000 units. That's awesome. I think
  385. whatever we can do to simplify this
  386. process, the point is don't wait until
  387. this patient's rolling through the door
  388. to make a decision about how you're
  389. going to reverse. Know what your
  390. hospital's policy is, like from the
  391. beginning. Know what people are
  392. comfortable with, what the pharmacist
  393. is comfortable with, how long it's
  394. gonna take to get these agents to
  395. bedside before you're actually in the
  396. moment dealing with these patients
  397. All right, so we have, we've
  398. identified the bleed, we have
  399. controlled their blood pressure, we
  400. have addressed whether or not they're
  401. antifigulated and have appropriately
  402. reversed them. The final thing to sort
  403. of think about in the upfront management
  404. of these ICH patients is whether or not
  405. there is probable ICP issues or
  406. hydrocephalus.
  407. Many of our patients who have deep basal
  408. ganglia or phthalamic bleeds will also
  409. have IVH Not every single IVH needs an
  410. external ventricular drain, but a lot
  411. of patients do. I think that's when you
  412. really need close collaboration with a
  413. neurosurgical colleague. So we know
  414. that that type of surgical intervention
  415. really is life-saving for many patients.
  416. Surgical options beyond just placing an
  417. EVD for hydrocephalus management,
  418. that's a little trickier The trials
  419. really have not been definitive that we
  420. help people with surgical treatments.
  421. We keep trying to find who is the right
  422. patient population? What's the right
  423. time? What is the right surgical
  424. technique? How do we make this most
  425. minimally invasive? Again, work
  426. closely with your neurosurgical
  427. colleagues for this patient population.
  428. We're gonna
  429. spend a whole episode talking about sort
  430. of medical management of intracranial
  431. pressure. So we'll skip that now. Just
  432. kind of keep in mind, like, does this
  433. patient look like they're getting sleepy?
  434. Is there evidence of uncle or
  435. trans-tentorial herniation? And then
  436. think about how am I gonna - And write
  437. that. All right, so yeah, so any like
  438. parting wisdom in terms of ICH
  439. management, take away points? I think
  440. this covered at all. I think just to
  441. highlight an echo that time is brain
  442. really, whatever you can do to fastest
  443. blood pressure management, I think
  444. reversal into studying of AC related ICH,
  445. those two really should happen kind of
  446. hand-in-hand. Just one thing to
  447. highlight also that and all the studies
  448. that looked at. I see for versatile
  449. understanding of anti-quagulation. Not
  450. a lot of them actually report a blood
  451. pressure management in that timeframe.
  452. So that's just one thing to think about
  453. whenever you're looking at these trials,
  454. are they reporting blood pressure? What
  455. was the blood pressure? What was that
  456. range during that first six hours,
  457. which is the initial expansion and
  458. damage happened. So some of those
  459. pearls, but I think hopefully this can
  460. help people with their initial
  461. managementization to ED or other ICUs
  462. are being neurocritical care unit, if
  463. you're new and you wanna learn the
  464. basics and the pearls, I think
  465. hopefully this is helpful. I love it.
  466. All right, we'll be back with another
  467. episode, this time focused on
  468. intracranial pressure, and so we hope
  469. you will stick around and join us. And
  470. again, thanks so much for listening.