Central nervous system disorders

I./4.5.: Treatment

Increased intracranial pressure reduced by controlled hyperventilation in case of hypnoid unconsciousness. Hypertonic solutions are not recommended because of the rebound effect (solutions diffuse into the bleeding and accumulate free water by their osmotic effect). Effectiveness of steroid use in hemorrhages is not proved. Progression of hematoma growth tends to stop by decreasing the systemic blood pressure, but significant decrease also decreases perfusion pressure result in global cerebral ischemia on the other hand. Leading USA recommendation say, that mean arterial pressure should be kept under 130 Hgmm, and cerebral perfusion pressure should reach 70 Hgmm. Vasodilatating antihypertensive are contraindicated because of the possibility of hematoma growth.

Hemorrhages developed as complication of heparin therapy should be treated with protamin sulphate (chlorate), counting on the dose and time elapsed from the drug given. Patients with bleedings from warfarin or coumarin treatment should be given intravenous K-vitamin and fresh frozen plasma at first place, concentrated prothrombin complex or facto IX complex might be considerate. Hematoma growth effectively decreased by recombinant factor VII infusion started in four-hour period. Although mortality from the bleeding is significantly lower in the treatment group, but severe thromboembolic complication (cerebral and myocardial infarction, pulmonary embolism) develop in more patients, which makes the procedure not recommended.

In patients with mechanical valves, anticoagulant treatment has to continue despite of the bleeding. In hemiparetic patients, prophylactic LMWH could be given preventing lower limb deep vein thrombosis from the fourth postictal day.