Intracerebral hemorrhage secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Secondary prevention

Life style modification

Life style modification measures which may help reduce the risk of intracerebral hemorrhage recurrent may include:

• Eating healthy balanced diet
• Smoking cessation
• Decreased alcohal intake
• Improved support from health care providers & care takers
• Patient education (involvement in BP monitoring to improve adherence to therapy)

Prevention of recurrent ICH

Blood pressure control

Receive early treatment targeted to an SBP level <140 mmHg to improve the chances of achieving better functional recovery

Restarting anticoagulation

Restarting anticoagulation should be avoided, UNLESS the risk of ischemic stroke is MUCH HIGHER than that of recurrent ICH.

• In AF patients with warfarin-associated lobar ICH or suspected CAA, the risk ICH recurrence seems higher than thromboembolic events. Therefore, the best management is to discontinue warfarin therapy.

• In patients with lobar ICH and CHADS2 VASc score > 5
  • LAA closure is a viable option
  • If LAA is not feasible oral anticoagulation (OAC) is considered
  • The use of DOACS (e.g. Apixaban) might be an alternative to warfarin
• In warfarin-related ICH patients with prosthetic valves
  • The risk of thromboembolic events is higher than the risk of recurrent ICH (resumption of OAC with warfarin is often required)
• The optimal time to resumption of anticoagulation after warfarin-related ICH is unclear and may vary from patient to patient
• Avoidance of oral anticoagulation (OAC) for 4-8 weeks, in patients without mechanical heart valves, might decrease the risk of ICH recurrence

Prevention of complications

The preventive measures which may help prevent complications of intracerebral hemorrhage include:

• Use of intermittent pneumatic compression begun as early as the day of hospital admission 
• Prophylactic anticonvulsant medication has not been demonstrated to be beneficia. However, in a case of clinical seizures or electrographic seizures in patients with a change in mental status should be treated with antisezure drugs to prevent recurrence
• Proper positioning of patient, and the use of thick feed with the help of nasogastric tube for feeding to prevent aspiration pneumonia in patients with cranial nerve palsies affecting pharyngeal motility and gag reflex
• Pressure ulcers may be prevented by use of air mattress and regular change in position of patient

References

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