Intracranial Hemorrhage (ICH) and Increased Intracranial ...

Intracranial Hemorrhage (ICH) and Increased Intracranial Pressure (ICP) - Pathophysiology

ICH Management:

1. Manage Blood Pressure

  • Spontaneous ICH and SAH BP target: < 140-160

  • Avoid vasodilating agents (nitro-) because they increase cerebral blood volume and ICP

2. Neuroprotective Intubation

  • Before: +/- local lidocaine, +/- pre-treatment with Fentanyl 3mcg/kg then wait 3min, pre-ox (goal O2 >95%), paralysis + sedation

  • During: Minimize attempts, use glidescope

  • After: Minimize PEEP, EtCO2 35-40, Ensure adequate sedation

3. Address Coagulopathy

  • DOACs: Octaplex

  • Warfarin: Octaplex + Vitamin K

  • Heparin: Protamine Sulfate

  • If platelets < 100: consider platelet transfusion

4. Maintain Normals: Glucose, Temp

5. Manage ICP and Seizures if needed

ICP Physiology:


 • Low CO2 = constricts BV = temporarily reduces ICP (but also reduces CPP)

 • High CO2 = dilated BV = raises ICP 


 • Hypoxia = dilated BV = raise ICP (dilates BV directly and via lactic acid formation)


 • Hypotension = reactive dilated BV = raise ICP

 • Hypertension = potential expansion of bleed

 • CPP = MAP - ICP. Target MAP: 80. Why? Target CPP 60. High ICP: 20.


 • Increased metabolic demand = increased cerebral blood flow - raise ICP

Osmotic Agents:

 • Osmotic agents = increase osmolarity of blood = water leaves brain cells

Dr. Sarah Foohey @SarahFoohey

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Contributed by

Dr. Gerald Diaz
Board Certified Internal Medicine Hospitalist, GrepMed Editor in Chief 🇵🇭 🇺🇸 - Sign up for an account to like, bookmark and upload images to contribute to our community platform. Follow us on IG: | Twitter:
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