Neurocritical Care

Diagnosis/pathogenesis

Neurologic examination

Vital signs

NIH Stroke Scale and/or GCS score

CT or MRI scan of the brain

CT angiography or contrast-enhanced CT (to help identify patients at risk of hematoma expansion

and to evaluate for underlying structural lesions)

Medication history to identify agents that might produce coagulopathy

Blood glucose

INR

CBC

Chronic/poorly treated hypertension

Cocaine/other stimulant use

Ischemic stroke with hemorrhagic transformation

Chronic alcohol intake

Brain tumor

Arteriovenous malformation

Amyloid angiopathy

Anticoagulant reversal

Prompt anticoagulant reversal is necessary. Reversal of laboratory values does not mean that

hemostasis will occur in all cases, especially with the newer oral anticoagulants (Table 11).

rFVIIa is not recommended for reversal of anticoagulation because it only replaces one clotting

factor and does not appear to be effective for dabigatran reversal. However, if no other reversal

agents are available, rFVIIa may be an option for patients who cannot accept human blood products.

Two prospective studies suggest that platelet transfusion for patients taking antiplatelet agents with

Both studies included patients with a small, stable ICH. Primarily basal ganglia hemorrhages,

which are traditionally nonoperative

ii.

Patients receiving dual antiplatelet therapy were underrepresented in both studies.

Routine administration of platelet transfusion for any patient with ICH who took antiplatelet agents

before admission is not advisable.

Platelet transfusion is likely still indicated for patients who:

Have an urgent need for surgery or a ventriculostomy and have abnormal platelet function tests

(if available)

ii.

Have a large ICH, receiving antiplatelet agents and requiring neurosurgery

iii.

Have acute neurologic decline with an intracranial hemorrhage