Medical decompression for increased intracranial pressure Intubation and mechanical hyperventilation Dexamethasone (Decadron), 4 mg every 6 hours Mannitol, 0.5 to 1 g/kg every 4 hours intravenously (IV) Glycerol, 1 to 1.5 ounces orally every 6 hours Furosemide (Lasix), 40 mg (4 mg/min) IV* Control of hypertension

Labetalol, 10 mg IV, followed by 10-mg doses as needed Trimethaphan camsylate (Arfonad), 0.5 to l mg/min IV by drip Nitroprusside sodium, 15 to 200 mug/min

Hydralazine hydrochloride (Apresoline), 50 to 100 mg twice daily orally Reversal of bleeding diathesis Fresh frozen plasma Antihemophilic factor

Phytonadione (vitamin K, AquaMEPHYTON) 20 to 40 mg IV Platelet transfusion Fresh blood transfusion Surgical

Drainage of hematoma-stereotactic drainage or surgical evacuation Ventricular drainage or shunt

Removal of bleeding arteriovenous malformation or tumor

Repair of aneurysm

*FDA approved for this indication.

Modified from Chung C-S, Caplan LR: Parenchymatous brain hemorrhage. In Rakel RE (ed): Conn's Current Therapy Philadelphia, WB Saunders. 1995, p 794.

A burr hole is made, and the drainage instrument is guided stereotactically, using CT, to the core of the hematoma, which is then evacuated. Fibrinolytic agents also can be instilled to soften and lyse coagulated hematomas. As yet, there is too little experience to allow comparison of open versus stereotactic drainage of hematomas although stereotactic surgical aspiration of ICH is probably safe and is promising. 67] , y

Prognosis and Future Perspectives. Survival depends on the size and rapidity of development of the hematoma. ICHs are at first soft and dissect along white matter fiber tracts. If the patient survives the initial changes in ICP, blood is absorbed and a cavity or slit forms that may disconnect brain pathways. Patients with small hematomas located deep and near midline structures often suffer from secondary herniation and mass effect, and these patients have a high mortality rate. Survivors invariably have severe neurological deficits. In patients with medium-sized hematomas, the deficit varies with the location and size of the hematomas. Most patients survive with some residual neurological signs.

Recent studies show that ischemic pressure damage develops around the hematomas in ICH. This finding implies the necessity of new treatment strategies in the future. The recent development of stereotactic surgical aspiration is promising.

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