Portal de Periódicos da CAPES

Neurocritical care for intracranial haemorrhage: a systematic review of recent studies

2015; Elsevier BV; Volume: 115; Linguagem: Inglês

10.1093/bja/aev379

1471-6771

Rafael Badenes, Federico Bilotta,

Acute Ischemic Stroke Management

Intracerebral haemorrhage (ICH) is associated with significant early mortality (up to 50% at 30 days) and long-term morbidity (with permanent neurological deficits in 75–80% of patients) and represents a serious health issue worldwide. The past decade has seen a dramatic increase in clinical research on ICH diagnosis and treatment that has led to revision of the guidelines for the diagnosis and management of ICH from the American Heart Association and American Stroke Association in 2013. This systematic review reports recent clinical evidence (original studies published between September 2013 and July 2015) related to neurocritical care and intensive care unit management of patients with ICH. All but one publication included in this review report original studies related to managment of patients with intracerebral or subarachnoid haemorrhage. These include insights on risk stratification and neurocritical care or intensive care unit treatment, management of haemodynamic variables and mechanical ventilation (goal-directed fluid therapy, advanced haemodynamic monitoring, and avoidance of hyperoxia and hyperventilation), and pharmacological neuroprotection. Intracerebral haemorrhage (ICH) is associated with significant early mortality (up to 50% at 30 days) and long-term morbidity (with permanent neurological deficits in 75–80% of patients) and represents a serious health issue worldwide. The past decade has seen a dramatic increase in clinical research on ICH diagnosis and treatment that has led to revision of the guidelines for the diagnosis and management of ICH from the American Heart Association and American Stroke Association in 2013. This systematic review reports recent clinical evidence (original studies published between September 2013 and July 2015) related to neurocritical care and intensive care unit management of patients with ICH. All but one publication included in this review report original studies related to managment of patients with intracerebral or subarachnoid haemorrhage. These include insights on risk stratification and neurocritical care or intensive care unit treatment, management of haemodynamic variables and mechanical ventilation (goal-directed fluid therapy, advanced haemodynamic monitoring, and avoidance of hyperoxia and hyperventilation), and pharmacological neuroprotection. Editor's key points•Intracerebral haemorrhage (ICH) is a common and devastating type of stroke and is a leading cause of disability among adults.•Outcomes after spontaneous ICH remain poor, with mortality up to 50% at 30 days and permanent disability in 75–80% of survivors.•Recent clinical evidence provides insights into risk stratification and neurocritical care management to optimize outcome. •Intracerebral haemorrhage (ICH) is a common and devastating type of stroke and is a leading cause of disability among adults.•Outcomes after spontaneous ICH remain poor, with mortality up to 50% at 30 days and permanent disability in 75–80% of survivors.•Recent clinical evidence provides insights into risk stratification and neurocritical care management to optimize outcome. Intracerebral haemorrhage (ICH) is one of the most common and most devastating types of stroke and is a leading cause of disability among adults.1World Health Organization (WHO) Fact sheet number 310: the top ten causes of death.http://www.who.int/mediacentre/factsheets/fs310/en/Date: 2014Google Scholar, 2Chan S Hemphill 3rd, JC Critical care management of intracerebral hemorrhage.Crit Care Clin. 2014; 30: 699-717Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Occurrence of ICH is the result of a number of pathophysiological processes that lead to bleeding within the cranial vault as a result of blood vessel rupture and result in a localized haematoma in the brain parenchyma and associated compression of brain tissue.3Fogarty Mack P Intracranial haemorrhage: therapeutic interventions and anaesthetic management.Br J Anaesth. 2014; 113: ii17-ii25Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 4Kim BJ Kim JS Ischemic stroke subtype classification: an Asian viewpoint.J Stroke. 2014; 16: 8-17Crossref PubMed Google Scholar Outcomes after spontaneous ICH remain bleak, with mortality up to 50% at 30 days and complications of permanent neurological deficits and disability present in 75–80% of survivors.5van Asch CJ Luitse MJ Rinkel GJ van der Tweel I Algra A Klijn CJ Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis.Lancet Neurol. 2010; 9: 167-176Abstract Full Text Full Text PDF PubMed Scopus (1658) Google Scholar, 6Feigin VL Barker-Collo S McNaughton H Brown P Kerse N Long-term neuropsychological and functional outcomes in stroke survivors: current evidence and perspectives for new research.Int J Stroke. 2008; 3: 33-40Crossref PubMed Scopus (59) Google Scholar, 7Fan JS Huang HH Chen YC et al.Emergency department neurologic deterioration in patients with spontaneous intracerebral hemorrhage: incidence, predictors, and prognostic significance.Acad Emerg Med. 2012; 19: 133-138Crossref PubMed Scopus (61) Google Scholar, 8Palm F Henschke N Wolf J et al.Intracerebral haemorrhage in a population-based stroke registry (LuSSt): incidence, aetiology, functional outcome and mortality.J Neurol. 2013; 260: 2541-2550Crossref PubMed Scopus (38) Google Scholar Although ICH has traditionally lagged behind acute ischaemic stroke (AIS) and subarachnoid haemorrhage (SAH) in terms of evidence from clinical trials to guide management, the past decade has seen a dramatic increase in the clinical research on ICH diagnosis and treatment.9Domingues R Rossi C Cordonnier C Diagnostic evaluation for nontraumatic intracerebral hemorrhage.Neurol Clin. 2015; 33: 315-328Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The American Heart Association/American Society of Anesthesiologists guidelines for management of patients with ICH, published in July 2015, includes a formal literature search updated to August 2013. Class 1 recommendations for neurocritical care (NCC) and intensive care unit (ICU) management are listed (Table 1).10Hemphill 3rd, JC Greenberg SM Anderson CS et al.Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2015; 46: 2032-2060Crossref PubMed Scopus (1929) Google ScholarTable 1Class I recommendations from AHA/ASA guidelines for optimal clinical management of patients with ICH relevant for neurocritical care. BP, blood pressure; DVT, deep vein thrombosis; ICH, intracerebral haemorrhage; ICU, intensive care unit; INR, international normalized ratio; SAP, systolic arterial pressure; VKA, vitamin K antagonistClass I Recommendation General monitoringMonitoring and clinical management should take place in an ICU or dedicated stroke unit run by physician neuroscience acute care expertise Arterial blood pressure managementFor ICH patients presenting with SAP between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SAP to 140 mm Hg is safe and can be effective for improving functional outcome Haemostasis and coagulopathy, antiplatelet agents, and DVT prophylaxis (i)Coagulation factors or platelet replacement, or both when needed(ii)If INR is elevated because of VKA, withhold VKA therapy, replace vitamin K-dependent factors, and give vitamin K i.v. to correct INR(iii)Intermittent pneumatic leg compression beginning on hospital admission to prevent venous thromboembolism Glucose managementGlucose should be monitored. Both hyperglycaemia and hypoglycaemia should be avoided Seizures and antiseizure drugsClinical seizures should be treated with antiseizure drugs. Patients with a change in mental status who are found to have electrographic seizures should be treated with antiseizure drugs Management of medical complicationsA formal screening procedure for dysphagia should be performed in all patients before initiation of oral intake to reduce the risk of pneumonia Prevention of recurrent ICHBP should be controlled in all ICH patients. Measures to control BP should begin immediately after ICH Open table in a new tab The purpose of this systematic review is to report recent clinical evidence, including original studies published between September 2013 and July 2015, related to NCC and ICU management of patients with ICH (spontaneous and post-traumatic) and SAH. A systematic literature search of PubMed, Medline, Current Controlled Trials, and EMBASE was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement recommendations.11Liberati A Altman DG Tetzlaff J et al.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.Br Med J. 2009; 339: b2700Crossref PubMed Scopus (11012) Google Scholar Clinical literature (prospective randomized clinical trials, observational studies, and case series that have enrolled more than five patients) were searched using the PubMed database. The following search terms were used: 'brain injury' AND 'intracranial haemorrhage' (spontaneous and post-traumatic). The following filters were used: clinical studies; published between September 2013 and July 2015; full-length articles (no abstracts); and English language. After hand searching and revision of the full text, duplicates were eliminated.12Bilotta F Gelb AW Stazi E Titi L Paoloni FP Rosa G Pharmacological perioperative brain neuroprotection: a qualitative review of randomized clinical trials.Br J Anaesth. 2013; 110: i113-i120Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar Details of the studies were recorded using a dedicated data-extraction form. Titles, abstracts, or both, of studies retrieved using the search strategy and those from additional sources were screened independently, and the full text of potentially eligible studies was retrieved and assessed independently for eligibility. Disagreement over eligibility was resolved through open discussion. A total of 51 articles were retrieved using the listed keywords. After screening for eligibility, 37 articles were excluded and 14 articles were selected (Fig. 1) and categorized into the following four subcategories: risk stratification and NCC or ICU treatment,13Akiyama H Uchino K Hasegawa Y Characteristics of symptomatic intracranial haemorrhage in patients receiving non-vitamin K antagonist oral anticoagulant therapy.PLoS ONE. 2015; 10: e0132900Google Scholar, 14Tobochnik S Gutierrez C Jacobson MP Characteristics and acute outcomes of ICU patients with initial presentation of seizure.Seizure. 2015; 26: 94-97Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 15Alonso A Ebert AD Kern R Rapp S Hennerici MG Fatar M Outcome predictors of acute stroke patients in need of intensive care treatment.Cerebrovasc Dis. 2015; 40: 10-17Crossref PubMed Scopus (33) Google Scholar, 16Nishijima DK Melnikow J Tancredi DJ et al.Long-term neurological outcomes in adults with traumatic intracranial hemorrhage admitted to ICU versus floor.West J Emerg Med. 2015; 16: 284-290Crossref PubMed Scopus (3) Google Scholar haemodynamic management,17Weiss A Beloosesky Y Kenett RS Grossman E Change in systolic blood pressure during stroke, functional status, and long-term mortality in an elderly population. Am J Hypertens Advance Access published on July 24, 2015.doi:10.1093/ajh/hpv118Google Scholar, 18Mutoh T Kazumata K Terasaka S Taki Y Suzuki A Ishikawa T Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage.Stroke. 2014; 45: 1280-1284Crossref PubMed Scopus (58) Google Scholar, 19Kissoon NR Mandrekar JN Fugate JE Lanzino G Wijdicks EF Rabinstein AA Positive fluid balance is associated with poor outcomes in subarachnoid hemorrhage.J Stroke Cerebrovasc Dis. 2015; 24: 2245-2251Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 20Joffe AM Khandelwal N Hallman MR Treggiari MM Assessment of circulating blood volume with fluid administration targeting euvolemia or hypervolemia.Neurocrit Care. 2015; 22: 82-88Crossref PubMed Scopus (6) Google Scholar, 21Chan E Anderson CS Wang X INTERACT2 Investigators et al.Significance of intraventricular hemorrhage in acute intracerebral hemorrhage: intensive blood pressure reduction in acute cerebral hemorrhage trial results.Stroke. 2015; 46: 653-658Crossref PubMed Scopus (29) Google Scholar, 22Yang J Arima H Wu G INTERACT Investigators et al.Prognostic significance of perihematomal edema in acute intracerebral hemorrhage: pooled analysis from the intensive blood pressure reduction in acute cerebral hemorrhage trial studies.Stroke. 2015; 46: 1009-1013Crossref PubMed Scopus (100) Google Scholar mechanical ventilation,23Rincon F Kang J Maltenfort M et al.Association between hyperoxia and mortality after stroke: a multicenter cohort study.Crit Care Med. 2014; 42: 387-396Crossref PubMed Scopus (172) Google Scholar, 24Solaiman O Singh JM Hypocapnia in aneurysmal subarachnoid hemorrhage: incidence and association with poor clinical outcomes.J Neurosurg Anesthesiol. 2013; 25: 254-261Crossref PubMed Scopus (35) Google Scholar and pharmacological neuroprotection25Höllig A Thiel M Stoffel-Wagner B Coburn M Clusmann H Neuroprotective properties of dehydroepiandrosterone-sulfate and its relationship to interleukin 6 after aneurysmal subarachnoid hemorrhage: a prospective cohort study.Crit Care. 2015; 19: 231Crossref PubMed Scopus (18) Google Scholar, 26Rasmussen R Wetterslev J Stavngaard T Effects of prostacyclin on cerebral blood flow and vasospasm after subarachnoid hemorrhage: randomized, pilot trial.Stroke. 2015; 46: 37-41Crossref PubMed Scopus (19) Google Scholar (Table 2).Table 2Characteristics of studies included in this systematic review. BV, blood volume; DHEAS, dehydroepiandrosterone sulfate; EGDFT, early goal-directed fluid therapy; HV, hypervolaemia; ICH, intracranial haemorrhage; ICU, intensive care unit; IVH, intraventricular haemorrhage; NA, not available; NOAC, novel oral anticoagulant; NV, normovolaemia; PHE, early perihaematomal oedema; SAP, systolic arterial pressureStudyStudy designnPrimary end pointMortality (%)ConclusionAkiyama and colleagues13Akiyama H Uchino K Hasegawa Y Characteristics of symptomatic intracranial haemorrhage in patients receiving non-vitamin K antagonist oral anticoagulant therapy.PLoS ONE. 2015; 10: e0132900Google ScholarRetrospective cohort6Incidence, clinical characteristics, and treatment course of patients with NOAC-associated ICH16.6Haematoma volume during NOAC therapy was small and did not expand in the absence of infusion of reversal agents or haemodialysisTobochnik and colleagues14Tobochnik S Gutierrez C Jacobson MP Characteristics and acute outcomes of ICU patients with initial presentation of seizure.Seizure. 2015; 26: 94-97Abstract Full Text Full Text PDF PubMed Scopus (6) Google ScholarRestrospective cohort247Composite in-hospital death or discharge to hospice7.7Death and discharge to hospice were relatively uncommon in ICU patients with seizuresAlonso and colleagues15Alonso A Ebert AD Kern R Rapp S Hennerici MG Fatar M Outcome predictors of acute stroke patients in need of intensive care treatment.Cerebrovasc Dis. 2015; 40: 10-17Crossref PubMed Scopus (33) Google ScholarRestrospective cohort347Short-term outcome and outcome predictors in acute stroke patients in need of ICU treatment41.2Functional outcome was poor, especially in older patientsNishijima and colleagues16Nishijima DK Melnikow J Tancredi DJ et al.Long-term neurological outcomes in adults with traumatic intracranial hemorrhage admitted to ICU versus floor.West J Emerg Med. 2015; 16: 284-290Crossref PubMed Scopus (3) Google ScholarRestrospective cohort151Comparison of long-term neurological outcomes in low-risk patients with traumatic ICH for patients admitted to the ICU vs regular ward0 to 1For low-risk patients with traumatic ICH, there were no differences in the long-term neurological outcomeWeiss and colleagues17Weiss A Beloosesky Y Kenett RS Grossman E Change in systolic blood pressure during stroke, functional status, and long-term mortality in an elderly population. Am J Hypertens Advance Access published on July 24, 2015.doi:10.1093/ajh/hpv118Google ScholarRestrospective cohort150Relationship between a spontaneous change in BP and short- and long-term outcomes38.6In elderly patients, the spontaneous change in 24 h SAP was not associated with short-term functional status and long-term mortalityMutoh and colleagues18Mutoh T Kazumata K Terasaka S Taki Y Suzuki A Ishikawa T Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage.Stroke. 2014; 45: 1280-1284Crossref PubMed Scopus (58) Google ScholarTwo-centre, prospective, randomized, non-blinded160Determine whether EGDFT improves outcomes compared with standard less-invasive haemodynamic therapyNAEGDFT can reduce the incidence of DCI and improve functional outcome at 3 monthsKissoon and colleagues19Kissoon NR Mandrekar JN Fugate JE Lanzino G Wijdicks EF Rabinstein AA Positive fluid balance is associated with poor outcomes in subarachnoid hemorrhage.J Stroke Cerebrovasc Dis. 2015; 24: 2245-2251Abstract Full Text Full Text PDF PubMed Scopus (36) Google ScholarRestrospective cohort288Association between positive fluid balance and clinical outcomesNAPositive net fluid balance was independently associated with poorer functional outcomeJoffe and colleagues20Joffe AM Khandelwal N Hallman MR Treggiari MM Assessment of circulating blood volume with fluid administration targeting euvolemia or hypervolemia.Neurocrit Care. 2015; 22: 82-88Crossref PubMed Scopus (6) Google ScholarProspective cohort39Evaluation of the BV of patients with NV or HVNAPatients treated with NV or HV had similar BVChan and colleagues21Chan E Anderson CS Wang X INTERACT2 Investigators et al.Significance of intraventricular hemorrhage in acute intracerebral hemorrhage: intensive blood pressure reduction in acute cerebral hemorrhage trial results.Stroke. 2015; 46: 653-658Crossref PubMed Scopus (29) Google ScholarData from INTERACT2, open-blinded end-point, randomized controlled trial2613Risk associations of IVH and outcomes20 with IVH; 9 without IVHIVH was a major independent prognostic factorYang and colleagues22Yang J Arima H Wu G INTERACT Investigators et al.Prognostic significance of perihematomal edema in acute intracerebral hemorrhage: pooled analysis from the intensive blood pressure reduction in acute cerebral hemorrhage trial studies.Stroke. 2015; 46: 1009-1013Crossref PubMed Scopus (100) Google ScholarData from INTERACT1 and 2 blinded end-point, randomized controlled trial1138Association of PHE and clinical outcome11Growth in PHE had independent prognostic significanceRincon and colleagues23Rincon F Kang J Maltenfort M et al.Association between hyperoxia and mortality after stroke: a multicenter cohort study.Crit Care Med. 2014; 42: 387-396Crossref PubMed Scopus (172) Google ScholarRestrospective cohort2894Relationship between hyperoxia and outcome in ventilated patients52Hyperoxia was independently associated with increased in-hospital deathSolaiman and colleagues24Solaiman O Singh JM Hypocapnia in aneurysmal subarachnoid hemorrhage: incidence and association with poor clinical outcomes.J Neurosurg Anesthesiol. 2013; 25: 254-261Crossref PubMed Scopus (35) Google ScholarRestrospective cohort102Incidence of hypocapnia and its association with clinical outcomes32Hypocapnia was very common, and the duration of hypocapnia was independently associated with unfavourable clinical outcomesHöllig and colleagues25Höllig A Thiel M Stoffel-Wagner B Coburn M Clusmann H Neuroprotective properties of dehydroepiandrosterone-sulfate and its relationship to interleukin 6 after aneurysmal subarachnoid hemorrhage: a prospective cohort study.Crit Care. 2015; 19: 231Crossref PubMed Scopus (18) Google ScholarProspective observational75Evaluation of DHEAS serum concentrations and concentrations of interleukin-6 related to functional outcomeNADHEAS was associated with protective propertiesRasmussen and colleagues26Rasmussen R Wetterslev J Stavngaard T Effects of prostacyclin on cerebral blood flow and vasospasm after subarachnoid hemorrhage: randomized, pilot trial.Stroke. 2015; 46: 37-41Crossref PubMed Scopus (19) Google ScholarRandomized, blinded, clinical trial90Effects of prostacyclin on cerebral blood flow3.3Prostacyclin did not increase the net perfusion of the brain Open table in a new tab Recent literature provides insights on risk stratification of ICH in patients receiving non-vitamin K-antagonist anticoagulants [new oral anticoagulants (NOACs)] and in patients presenting with seizures, co-morbidity and complications associated with ICU treatment, and on limited benefit of ICU treatment in low-risk patients presenting with post-traumatic ICH.13Akiyama H Uchino K Hasegawa Y Characteristics of symptomatic intracranial haemorrhage in patients receiving non-vitamin K antagonist oral anticoagulant therapy.PLoS ONE. 2015; 10: e0132900Google Scholar, 14Tobochnik S Gutierrez C Jacobson MP Characteristics and acute outcomes of ICU patients with initial presentation of seizure.Seizure. 2015; 26: 94-97Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 15Alonso A Ebert AD Kern R Rapp S Hennerici MG Fatar M Outcome predictors of acute stroke patients in need of intensive care treatment.Cerebrovasc Dis. 2015; 40: 10-17Crossref PubMed Scopus (33) Google Scholar, 16Nishijima DK Melnikow J Tancredi DJ et al.Long-term neurological outcomes in adults with traumatic intracranial hemorrhage admitted to ICU versus floor.West J Emerg Med. 2015; 16: 284-290Crossref PubMed Scopus (3) Google Scholar Clinical characteristics and the relationship with arterial blood pressure of ICH associated with chronic use of NOACs is reported in a retrospective cohort study in six patients (five receiving rivaroxaban and one apixaban).13Akiyama H Uchino K Hasegawa Y Characteristics of symptomatic intracranial haemorrhage in patients receiving non-vitamin K antagonist oral anticoagulant therapy.PLoS ONE. 2015; 10: e0132900Google Scholar In these patients, the mean time to onset was 146 (sd 112) days after starting NOACs, and mean systolic arterial pressure (SAP; recorded 1 month before ICH) was 138 (16) mm Hg. Although none of the therapies traditionally used to counteract coagulation abnormalities (infusion of fresh frozen plasma, activated prothrombin complex concentrate, recombinant activated factor VIIa, or haemodialysis) was used, ICH was not associated with haematoma expansion within the 24 h after onset of symptoms. The authors highlight how ICH occurred relatively soon after the start of NOAC therapy, and haematoma volume was small. These findings suggest that even stricter arterial pressure lowering and control within an acceptable range may be advisable to prevent ICH during NOAC therapy. The relevance of seizures at presentation and relationship with in-hospital mortality was evaluated in a retrospective cohort study that recruited 247 patients presenting with seizures to the emergency department and admitted to the ICU for treatment.14Tobochnik S Gutierrez C Jacobson MP Characteristics and acute outcomes of ICU patients with initial presentation of seizure.Seizure. 2015; 26: 94-97Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In this subgroup of patients, ICH was detected as a possible underlying cause of the seizures in 36 of 247 patients (14.5%). Overall, in-hospital death occurred in 7.7%. The authors concluded that rates of death and discharge to hospice were relatively low in this patient population. Associated complications (cardiac and ventilatory), intensity of treatment (with mechanical ventilation), and the relationship with short-term outcome, were evaluated in a retrospective cohort study in 347 patients with AIS or ICH in a series of 4958 patients admitted to a stroke unit.15Alonso A Ebert AD Kern R Rapp S Hennerici MG Fatar M Outcome predictors of acute stroke patients in need of intensive care treatment.Cerebrovasc Dis. 2015; 40: 10-17Crossref PubMed Scopus (33) Google Scholar Besides stroke-related disturbances of consciousness that complicated 47.1%, the most commonly reported reasons for ICU treatment were as follows: cardiac (23.4%), respiratory (12.1%), or complications of interventional procedures requiring mechanical ventilation (11%). Mechanical ventilation was needed in 231 of 347 patients (66.6%) for a mean of 84 h. Overall in-hospital mortality (143 of 347; 41.2%) was associated with older age, poor National Institute of Health Stroke Scale (NIHSS) score at admission, and the need for mechanical ventilation (P<0.001). In patients ≥80 yr old with ICH, the need for mechanical ventilation was strongly associated with an unfavourable outcome. Overall post-rehabilitation outcome did not differ between patients with ICH and AIS. The authors conclude that ICU admission is associated with a life-saving outcome even among the elderly. However, functional outcome was poor in older patients, thus limiting the benefits of ICU treatment. Use of the ICU or regular ward admission to treat 'low-risk' patients presenting with minor traumatic ICH was investigated in a retrospective cohort study to compare long-term neurological outcomes, measured with the extended Glasgow Outcome Scale (GOS) score at 6 months follow-up.16Nishijima DK Melnikow J Tancredi DJ et al.Long-term neurological outcomes in adults with traumatic intracranial hemorrhage admitted to ICU versus floor.West J Emerg Med. 2015; 16: 284-290Crossref PubMed Scopus (3) Google Scholar Low-risk patients were defined as follows: age <65 yr, isolated head injury, normal admission mental status, and no shift or swelling on initial head computed tomography (CT). Of 151 patients studied, 45 (30%) were admitted to the ward and 106 (70%) to the ICU. In 23 patients admitted to the ward and in 55 patients admitted to the ICU, the 6 months GOS was normal [51% (95% confidence interval 36–66%) vs 52% (95% confidence interval 42–62%)]. The authors conclude that in low-risk patients with traumatic ICH, there are no differences in the long-term neurological outcome after admission to a regular ward or ICU. However, they were unable to demonstrate non-inferiority on adjusted analysis. Several aspects of the haemodynamic management of patients with ICH have been investigated. These include the relationship between lowering SAP, use of early goal-directed fluid therapy (EGDFT), and positive net fluid balance with functional follow-up and delayed cerebral ischaemia (DCI) after ICH or SAH.17Weiss A Beloosesky Y Kenett RS Grossman E Change in systolic blood pressure during stroke, functional status, and long-term mortality in an elderly population. Am J Hypertens Advance Access published on July 24, 2015.doi:10.1093/ajh/hpv118Google Scholar, 18Mutoh T Kazumata K Terasaka S Taki Y Suzuki A Ishikawa T Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage.Stroke. 2014; 45: 1280-1284Crossref PubMed Scopus (58) Google Scholar, 19Kissoon NR Mandrekar JN Fugate JE Lanzino G Wijdicks EF Rabinstein AA Positive fluid balance is associated with poor outcomes in subarachnoid hemorrhage.J Stroke Cerebrovasc Dis. 2015; 24: 2245-2251Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 20Joffe AM Khandelwal N Hallman MR Treggiari MM Assessment of circulating blood volume with fluid administration targeting euvolemia or hypervolemia.Neurocrit Care. 2015; 22: 82-88Crossref PubMed Scopus (6) Google Scholar A secondary analysis of INTERACT1 and 2 provided information about the association between intraventricular haemorrhage (IVH) and early perihaematomal oedema with outcome.21Chan E Anderson CS Wang X INTERACT2 Investigators et al.Significance of intraventricular hemorrhage in acute intracerebral hemorrhage: intensive blood pressure reduction in acute cerebral hemorrhage trial results.Stroke. 2015; 46: 653-658Crossref PubMed Scopus (29) Google Scholar, 22Yang J Arima H Wu G INTERACT Investigators et al.Prognostic significance of perihematomal edema in acute intracerebral hemorrhage: pooled analysis from the intensive blood pressure reduction in acute cerebral hemorrhage trial studies.Stroke. 2015; 46: 1009-1013Crossref PubMed Scopus (100) Google Scholar In a retrospective cohort study, the impact of lowering SAP during the first week of stroke and the relationship with functional status and long-term mortality were assessed in 150 elderly patients (mean age at admission 83.6 sd 5.5 yr) with AIS (82.7%) or ICH (10%).17Weiss A Beloosesky Y Kenett RS Grossman E Change in systolic blood pressure during stroke, functional status, and long-term mortality in an elderly population. Am J Hypertens Advance Access published on July 24, 2015.doi:10.1093/ajh/hpv118Google Scholar Outcome was measured with modified Rankin Scale (mRS) after 1 week and mortality at long-term follow-up (mean follow-up 7.5 yr). Within 7 days after admission, SAP was effectively lowered (using one or more of the following: calcium antagonists, β-blockers, diuretics, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and α-blockers) from 147 (21) to 140 (20) mm Hg; P<0.001. Mean admission SAP predicted short-term functional status and long-term mortality, but there was no association between the change in SAP attained during the first week after str