title: The critical care management of spontaneous intracranial hemorrhage: a contemporary review.
abstract: Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.
authors.affiliation: Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital-University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. airtonleo.manoel@gmail.com.|Department of Critical Care Medicine, Trauma & Neurosurgical Intensive Care Unit, St. Michael's Hospital-University of Toronto, Toronto, ON, Canada. airtonleo.manoel@gmail.com.|Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada. airtonleo.manoel@gmail.com.
authors.forename: Airton Leonardo
authors.identifier: http://orcid.org/0000-0002-9593-1013
authors.initials: AL
authors.lastname: de Oliveira Manoel
authors.affiliation: Department of Medicine, Division of Respirology (Critical Care), University Health Network, Toronto, ON, Canada.|Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Alberto
authors.initials: A
authors.lastname: Goffi
authors.affiliation: Intensive Care Unit, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.|Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
authors.forename: Fernando Godinho
authors.initials: FG
authors.lastname: Zampieri
authors.affiliation: Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital-University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Turkel-Parrella
authors.affiliation: Medical Intensive Care Unit, Department of Pulmonary, Allergy, and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.|Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
authors.forename: Abhijit
authors.initials: A
authors.lastname: Duggal
authors.affiliation: Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital-University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Marotta
authors.affiliation: Department of Surgery, Division of Neurosurgery, St. Michael's Hospital-University of Toronto, Toronto, ON, Canada.
authors.forename: R Loch
authors.initials: RL
authors.lastname: Macdonald
authors.affiliation: Department of Critical Care Medicine, Trauma & Neurosurgical Intensive Care Unit, St. Michael's Hospital-University of Toronto, Toronto, ON, Canada.|Department of Anesthesiology, St. Michael's Hospital-University of Toronto, Toronto, ON, Canada.
authors.forename: Simon
authors.initials: S
authors.lastname: Abrahamson
mesh_terms: D000925:Anticoagulants / Q000494:pharmacology / Q000627:therapeutic use; D003422:Critical Care / Q000379:methods*; D019468:Disease Management; D006490:Hemostatics / Q000494:pharmacology / Q000627:therapeutic use; D006801:Humans; D006973:Hypertension / Q000150:complications; D007362:Intensive Care Units / Q000458:organization & administration; D020300:Intracranial Hemorrhages / Q000209:etiology / Q000628:therapy*; D012307:Risk Factors; D012422:Rupture, Spontaneous / Q000150:complications* / Q000628:therapy; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed / Q000379:methods
chemical_list: D000925:Anticoagulants; D006490:Hemostatics