JR-ZQSI-NICHE

Jose Reyes-Zeenat Qureshi Stroke Institute

Neurology and Neurosurgery Intracerebral Hemorrhage Evaluation

The following algorithm is adapted and modified from "Indication, Timing, and Surgical Treatment of Spontaneous Intracerebral Hemorrhage: Systematic Review and Proposal of a Management Algorithm" by Luzzi, et. al. published in World Neurosurgery in 2019. (https://doi.org/10.1016/j.wneu.2019.01.016))

Neurology and Neurosurgery Intracerebral Hemorrhage Evaluation

Coagulopathy-Induced

For a patient with coagulopathy-induced intracerebral hemorrhage, correction of INR or coagulopathy is suggested first.

Coagulopathy already corrected

Location of Hematoma

Location of Hematoma

Glasgow Coma Scale

Glasgow Coma Scale

Baseline volume of hematoma

Baseline volume of hematoma

Baseline volume of hematoma

Baseline volume of hematoma

Signs of increased ICP on monitoring*

*Including intracranial hypertension (pulsatility index >1.26 on transcranial coppler), lateral reclus palsy, absent or compressed systems. mid line shift >0.5 cm

Indicators Suggestive of Increased ICP:

- PI > 1.2 on TCD
- Lateral Rectus Palsy
- Midline Shift > 0.5 cm
- Effacement or Obliteration of Basal Cisterns

Early Surgical Intervention

For a patient , surgical management is recommended.

Hydrocephalus

Medical Management

For a patient , medical management is recommended.

Widest diameter

Brainstem compression +/- hydrocephalus

Signs of increased ICP (Intracranial hypertension/ LR palsy)/ Absent or compressed cisterns/ Midline shift >0.5cm

Indicators Suggestive of Increased ICP:

- PI > 1.2 on TCD
- Lateral Rectus Palsy
- Midline Shift > 0.5 cm
- Effacement or Obliteration of Basal Cisterns

Indicators Suggestive of Increased ICP:

- PI > 1.2 on TCD
- Lateral Rectus Palsy
- Midline Shift > 0.5 cm
- Effacement or Obliteration of Basal Cisterns

Signs of increased ICP*

*Including intracranial hypertension (pulsatility index >1.26 on transcranial doppler) and/or lateral rectus palsy

Stability / Improvement

Location of Hematoma

Deep

Superficial extension

Intraventricular hemorrhage/extension

For a patient with coagulopathy-induced intracerebral hemorrhage, correction of INR or coagulopathy is suggested first.

Glasgow Coma Scale/Score (GCS)

Best eye response

If local injury, edema, or otherwise unable to be assessed, mark "Not testable (NT)"

Spontaneously (+4)
To verbal command (+3)
To pain (+2)
No eye opening (+1)
Not testable (NT)

Best verbal response

If intubated or otherwise unable to be assessed, mark "Not testable (NT)"

Oriented (+5)
Confused (+4)
Inappropriate words (+3)
Incomprehensible sounds (+2)
No verbal response (+1)
Not testable/intubated (NT)

Best motor response

If on sedation/paralysis or unable to be assessed, mark "Not testable (NT)"

Obeys commands (+6)
Localizes pain (+5)
Withdrawal from pain (+4)
Flexion to pain (+3)
Extension to pain (+2)
No motor response (+1)
Not testable (NT)
Legend:
  • Best response(15)
  • Comatose client (8 or less)
  • Totally unresponsive (3)

ICH Volume

Intracerebral Hemorrhage Volume

Result:
Legend:
  • <10mL - Small hemorrhage
  • 10-30mL - Moderate hemorrhage
  • >30mL - Large hemorrhage

Contributors to the App

Conceptualization and Design:

Jose C. Navarro, MD, MSc, FPNA
Ma. Priscille T. Ogena, MD

Contributors:

Herminigildo H. Gan, MD, FPCP, FPNA
Romulo U. Esagunde, MD, FPNA
Joseph Erroll V. Navarro, MD, FAFNI, FPCS
Cyrus G. Escabillas, MD, FPNA
Maria Anna F. de Guzman, MD, FPNA
Steven G. Villaraza, MD, FPNA
Ma. Jeasa G. Torrefranca, MD
Josephine Cecilia V. Roque, MD