Continuum, February 2006, Volume 12, Issue 1

Intracerebral hemorrhage is the most devastating form of acute stroke. Hematoma growth after diagnosis is common and associated with worse outcome; therefore, early management is often considered critical. Several factors that predict poor outcome can be treated in the acute setting, including hypoxia, high blood pressure, pyrexia, hyperglycemia, edema, and seizure activity. In addition, surgical decompression can benefit selected patients, depending upon hematoma location and presence of mass effect. Early and careful management of airway, blood pressure, coagulopathy (including warfarin use), intracranial pressure, and serum glucose levels are mainstays of emergency management of intracerebral hemorrhage.(C) 2006 American Academy of Neurology

Accurately predicting the chances of awakening following cardiorespiratory arrest is important to help families make decisions about continued medical care. Falsely pessimistic predictions of never awakening (when awakening may have occurred if the patient was supported long enough) should be avoided. The vast majority (approximately 90%) of patients who will awaken do so within the first 3 days, and most patients should be supported for this duration. Absent motor response to pain or absent pupillary light reflex 3 days after cardiac arrest are strongly associated with never awakening. Early myoclonus frequently, but not uniformly, portends an ominous prognosis. Absent bilateral short-latency somatosensory evoked potentials may be the most reliable prognostic test available today, but the sensitivity for identifying patients who will not awaken runs only approximately 44%. Depending on local availability, electroencephalography and biochemical tests may provide supporting information. Imaging results, even with the use of modern magnetic resonance imaging techniques, have not been well-enough characterized in large blinded studies to be useful in predicting outcome.(C) 2006 American Academy of Neurology

Head injury is the most common cause of intracranial hypertension requiring intracranial pressure (ICP) monitoring, but other causes include spontaneous intracranial hemorrhage, tumors, stroke, and infection. In head injury, ICP monitoring is indicated in any patient with a Glasgow Coma Score less than 8 at admission and an abnormal computed tomographic scan of the head or two of the following: motor posturing, age greater than 40, or systemic hypotension. Goals for management include ICP less than 20 mm Hg and cerebral perfusion pressure between 60 mm Hg and 70 mm Hg. Mass lesions, including tumors and hematomas, warrant surgical intervention. For other causes of intracranial hypertension, head-up position, mannitol, hypertonic saline, and barbiturates are possible therapeutic options. Moderate hypothermia is an additional option, as is hyperventilation, although these latter therapies entail additional unique risks. Finally, decompressive craniectomy remains a controversial intervention for refractory intracranial hypertension.(C) 2006 American Academy of Neurology