Emergent anticoagulation reversal and BP control are key for ICH

In July, the American Stroke Association released 2022 guideline for management of spontaneous intracerebral hemorrhage (ICH) with recommendations acute ICH.“ICH has one highest case-fatalities among all strokes and often outcomes depend on disease progression in first 24 to 48 hours,” said Daniel Atashsokhan, MD, a PGY-2 department neurology at State University New York (SUNY) Downstate Medical School/One Brooklyn Health Program York, who was not involved writing. “Therefore, it requires system-based approach multidisciplinary coordination between stroke, neurocritical care, neurointerventional neurosurgical services that focus early aggressive management.”The key is preventing hematoma expansion—especially hours—due high correlation poor outcomes, Ambooj Tiwari, MPH, surgeon vascular neurologist (NYU) Grossman School Medicine, also guidelines. Hematoma expansion depends two specific aspects management: coagulopathy disease-related control or pharmacological reversal BP control.Emergent anticoagulation crucialIn applicable cases, emergent pathological target hyperacute therapy 60 minutes. For patients coumadin, 4-factor prothrombin complex concentrate (4F PCC) Vitamin K preferred reversal. The treatment goal reverse INR < 1.3 within 4 hours. Although typical dosing 25–50 IU/kg, some studies have used 1,500 IU fixed dose regimens. If 2.0, lower doses 10–20 IU/kg are recommended.Due time cost, obtaining blood tests confirm levels recommended, but using recent determine need advocated, Tiwari. agents were taken hours presentation, activated charcoal can be used.For direct thrombin inhibitors like dabigatran Factor Xa inhibitors, appropriate include idarucizumab andexanet alfa, respectively. When unavailable, recommends 4F PCC.In heparin low molecular weight heparins (LMWH), enoxaparin, guidelines recommend protamine. did find any advantage reversing antiplatelet activity those taking aspirin adenosine disphosphate (ADP) receptor although use platelet transfusion reasonable former—especially when an evacuation craniotomy planned, Ciraparantag new potential universal antidote anticoagulants.BP criticalAnother major aspect limiting control. Based data from trials (INTERACT2 ATACH-2) intensive lowering, guidelines’ recommended presenting initial systolic (SBP) 150–220 mm Hg reduce their 130–140 over 4.5–6 hours.“Ultra-aggressive lowering below range 2 seems lead worse as well cause renal injury,” “The [guideline] authors felt reduction 20 40 hour seemed most approach.”For SBP > 220 Hg, threshold 90 best order avoid injury, Tiwari.Most importantly, research team found significant variability phase outcomes.Therefore, antihypertensive rapid onset short duration action facilitate titrability.“There large knowledge gaps remaining which select whether administer bolus versus drip,” Steven Greenberg, PhD, director Hemorrhagic Research Massachusetts General Hospital professor Harvard Boston, MA, ICH updates.Hematoma managementMost postemergent care involves related complications aspiration, infections, cardiac arrythmias.“If stabilized serial CTs hours, starting DVT prophylaxis 48–96 since ICHs 7% incidence thromboembolic complications,” “Studies without intermittent pneumatic compression superior stockings.” ICH. “ICH management.” Emergent anticoagulants. recommended. Due used. PCC. updates. Another “Ultra-aggressive approach.” Most outcomes. Therefore, titrability. “There arrythmias. “If