Neurocritical care

Intracerebral hematomas (ICHs) are not static with one in three enlarging in size by 33%, leading to early neurological deterioration and worse outcome. While hemostatic therapy with recombinant factor VIIa reduces hematoma expansion when given early, it does not improve functional outcome. Aggressive acute lowering of high blood pressure after ICH may also minimally reduce expansion, but not sufficient to improve outcome. Some patients may benefit from surgical interventions, but more trials are planned to evaluate minimally invasive techniques and craniotomy for lobar ICH. Prognosis after ICH is best predicted by patient’s age, level of consciousness on admission, and neurological impairment measured using the NIH stroke scale. Aneurysmal subarachnoid hemorrhage (SAH) is complicated by rebleeding in up to 14% of cases, with the majority resulting in death or severe disability. Antifibrinolytic drug therapy, started immediately and continued only till early aneurysm treatment, reduces rebleeding without increasing the risk of cerebral ischemia. Developing cerebral infarcts associated with vasospasm greatly increases the risk of poor outcome after SAH. Nimodipine is effective in reducing ischemia and infarcts and improving outcome. While early studies of statins appear promising in demonstrating a reduction in vasospasm and ischemia, these results are preliminary, somewhat conflicting, and larger trials are waited. Prophylactic hypervolemic is not effective in preventing delayed ischemia and there is no controlled evidence that “Triple H” therapy (hypertension, hypervolemia, and/or hemodilution), while anecdotally effective in reversing symptoms of vasospasm, prevents infarction or improves ultimate outcome.