Neurocritical Care

Evidence also suggests that blood pressure fluctuations in the first 4–6 hours post-ICH are associated

with poor functional outcomes (Stroke 2018;49:348-54).

Large, international, multicenter, stepped-wedge cluster randomized trial aimed at assessing the

effect of a goal-directed care bundle on functional outcomes in patients with acute intracerebral

hemorrhage. The bundle, which included intensive blood pressure control (target less than 140 mm

Hg), glucose management, antipyrexia, and rapid anticoagulation reversal, was implemented within

6 hours of symptom onset. The care bundle group demonstrated a favorable shift in functional

outcomes on the modified Rankin Scale (mRS) at 6 months, with a common odds ratio of 0.86 (95%

CI, 0.76–0.97; P = .015) compared with the usual care group, suggesting improved recovery. A

significant portion of the effect size was attributed to intensive blood pressure control, with patients

in the care bundle group also experiencing fewer serious adverse events (16.0% vs 20.1%; P = .0098)

Seizure Prophylaxis. Use of anticonvulsants for seizure prophylaxis is not indicated after ICH.

VTE prophylaxis should be initiated about 24 hours after symptom onset or surgical evacuation.

Patient Case

Questions 3 and 4 pertain to the following case.

A 61-year-old man is admitted with acute onset of difficulty speaking, confusion, and right-sided weakness.

His NIH Stroke Scale score is 20. A head CT scan reveals a right parietal intracerebral hemorrhage (ICH).

The patient’s home medications include hydroxychloroquine, ibuprofen as needed, warfarin, amlodipine, and

donepezil. His medical history includes a deep venous thrombosis (1 year ago), hypertension, early dementia,

and arthritis. Serum laboratory values include Na 140 mEq/L, K 3.6 mEq/L, BUN 27 mg/dL, SCr 1.8 mg/dL,

glucose 289 mg/dL, Hct 36.7%, Plt 245,000/mm3, and INR 6.8. His vital signs include blood pressure 163/101

mm Hg, heart rate 99 beats/minute, Sao2 97%, and respiratory rate 20 breaths/minute.

Which is the most appropriate initial therapy in addition to vitamin K for this patient’s care?

For this 61-year-old patient with ICH, which is the most appropriate initial antihypertensive therapy?

Occurs in around 11.4 per 100,000 person-years. Worldwide incidence is around 6.1 per 100,000 person-

years.