Nurose Karim, MD 

International Stroke Conference 2022 
February 9–11, 2022 
Session: ICH Management: Now and Into the Next Decade 

ICH is a process that leads to many potential targets for intervention. Baseline characteristics (size, GCS, IVH, location and age) predict the outcome. Early hematoma growth leads to tissue disruption and activation of inflammatory markers causing toxic effects and oxidative injury. This causes neuronal injury followed by phagocytosis and active resolution of the inflammation.

Hematoma expansion occurs early, and in about a third of patients, it occurs in the first three hours. The sooner we identify and treat, the earlier we can prevent injury. For ICH, fortunately, we have better metrics. The goal of metrics is to reduce heterogenicity across the board and prevent early neurological deterioration. Due to COVID-19, we have a shortage of beds and nursing staff, and patients are staying in the ED longer than expected. Therefore, we need to train our ED staff to take care of ICH patients and need time metrics to consider: when to repeat imaging? time to ventricular drainage, if indicated? time to operative procedures?

For the reversal of coagulopathy, if the patient is on warfarin and INR is >1.4, we use 4-factor PCC (K-centra- onset of action ~30 mins and effect lasts for 4-6 hrs) and IV vitamin K. Andexanate Alpha is the specific reversal agent for rivaroxaban and apixaban. Idarucizumab is the agent of choice for dabigatran.

Regarding if and when to go for surgery, if the aim of surgery is to improve mortality, provide ease of care and have promising improvement in the functional outcome, then yes, patients should go for surgery, but this has to be tested in a randomized clinical trial. Intraventricular alteplase improves mortality but is unclear in terms of improving morbidity. It doesn’t reduce shunt dependency, though. In the next 10 years, we look forward to validation of newer approaches, including endoscopic removal of clot and lumbar drainage and improvement in weaning EVD. 2HELPS2B score can guide initiation of AED for seizure prophylaxis. Short-term (7-day) treatment is better than long-term.

The conclusion of the session was, this is an exciting time to study more about ICH.