Tratamiento de la hemorragia cerebral

Resolución de la hipertensión arterial si la hubiere.

Corregir la discrasia sanguínea

ver Tratamiento quirúrgico de la hemorragia cerebral.

Hemorragia Intracerebral en recién nacido.

La prueba diagnóstica de elección:

Ultrasonidos.

TAC indicado en los casos en que los hallazgos de ultrasonidos son dudosos (Variaciones anatómicas…)

Indicación quirúrgica.-

Sólo se evacuarán las infratentoriales que produzcan compresión del mesencéfalo con ventriculomegalia progresiva y que no responden a tratamiento médico.

Las supratentoriales que produzcan ventriculomegalia progresiva y que no respondan con tratamiento médico se tratarán con punción ventricular. En el caso de no resolverse se tratarán con shunt ventrículo-peritoneal.

Monitorización

La monitorización de la PbtO2, puede ser utilizado para identificar los objetivos de CPP para la oxigenación óptima del tejido cerebral.

En los pacientes que no se monitorizan de forma multimodalidad, el mantenimiento de la CPP > 80 mmHg puede reducir el riesgo de hipoxia cerebral tisular.

Pronóstico

Solo un 20 % podrán realizar una vida independiente 6 meses después.

El 50 % fallecen en el primer mes.

Los volúmenes de >60 cm3 tienen una mortalidad del 90 %

Conclusiones

No esta clara la estrategia a seguir.

Estudios mal diseñados.

Deben de agruparse en Localización, tamaño, GCS.

No agrupar sistemáticamente todos los tipos de intervención quirúrgica.

Hasta el momento, ninguna intervención en particular es claramente superior.

Una revisión de los estudios aleatorios disponibles, sin embargo indica que las opciones menos invasivas puedan mostrar resultados mejores.

Esto puede ser en particular verdadero en pacientes jóvenes con signos de deterioro neurológico reciente.

Reducir el volumen de hematoma permanece como pilar básico.

Las futuras investigaciones e intervenciones van indudablemente en esta dirección.

Este interés en identificar mecanismos bioquímicos refleja el aumento reciente de publicaciones de investigación de mecanismos celulares y moleculares

Mientras tanto, la responsabilidad permanece sobre el clínico para hacer el juicio terapéutico lo mejor posible.

Ingreso en una unidad de cuidados intensivos.

Soporte ventilatorio cuando esté indicado

Control de la presión arterial

Revertir cualquier coagulopatía preexistente

Monitorización de la presión intracraneal para ciertos casos

Osmoterapia

Control de la temperatura

Profilaxis de las convulsiones

Tratamiento de la hiperglucemia

Soporte nutricional

Resolución de la hipertensión arterial si la hubiere.

Corregir la discrasia sanguínea

Antiepilépticos

La evacuación del hematoma quirúrgico no mejora los resultados es controvertido.

El paciente ideal para una intervención quirúrgica:

1. Paciente que sufre deterioro neurológico de inicio reciente. 2. GCS entre 6 y 10 3. Edad igual o menor de 50 años. 4. Volumen de sangre entre 10 a 30 cc. con marcado efecto masa. 5. Localización lobar en hemisferio no dominante 6. Coagulación normal

Paciente con mal pronóstico a pesar de cirugía:

1.Deterioro que persiste 24 horas o más. 2.GCS menor de 5 3.Edad elevada (> 75 años) o enfermedad de base importante 4.Volumen de sangre mayor de 30 cc. 5.Hemorragia masiva en hemisferio dominante o área elocuente. 6.Coagulopatía severa

Hemorragia Intracerebral en recién nacido.

La prueba diagnóstica de elección:

Ultrasonidos.

TAC indicado en los casos en que los hallazgos de ultrasonidos son dudosos (Variaciones anatómicas…)

Indicación quirúrgica.-

Sólo se evacuarán las infratentoriales que produzcan compresión del mesencéfalo con ventriculomegalia progresiva y que no responden a tratamiento médico.

Las supratentoriales que produzcan ventriculomegalia progresiva y que no respondan con tratamiento médico se tratarán con punción ventricular. En el caso de no resolverse se tratarán con shunt ventrículo-peritoneal.

Los tratamientos experimentales prometedores incluyen actualmente el tratamiento con hemostático, la lisis del coágulo intraventricular con trombolíticos, pioglitazona, la modulación de la temperatura, y la deferoxamina para reducir la inflamación perihematoma mediado por hierro y la lesión tisular.

La fiebre y el crecimiento del hematoma son predictores independientes de mal pronóstico.

Se necesitan investigaciones futuras para estudiar los mecanismos de este fenómeno y analizar si los protocolos iniciales de modulación de la temperatura se asocia con mejores resultados (Rincon y col., 2012).

Solo un 20 % podrán realizar una vida independiente 6 meses después.

El 50 % fallecen en el primer mes.

Los volúmenes de >60 cm3 tienen una mortalidad del 90 %

El pronóstico final de los pacientes, no depende de una variable aislada, sino de la conjunción de varias; por ello se han intentado crear escalas pronósticas que las agrupen.

En la actualidad han surgido escalas breves, simples y con alta sensibilidad como la “ICH score” creada por Hemphill.

Enlace http://www.mdcalc.com/intracerebral-hemorrhage-ich-score/

No esta clara la estrategia a seguir.

Estudios mal diseñados.

Deben de agruparse en Localización, tamaño, GCS.

No agrupar sistemáticamente todos los tipos de intervención quirúrgica.

Hasta el momento, ninguna intervención en particular es claramente superior.

Una revisión de los estudios aleatorios disponibles, sin embargo indica que las opciones menos invasivas puedan mostrar resultados mejores.

Esto puede ser en particular verdadero en pacientes jóvenes con signos de deterioro neurológico reciente.

Reducir el volumen de hematoma permanece como pilar básico.

Las futuras investigaciones e intervenciones van indudablemente en esta dirección.

Este interés en identificar mecanismos bioquímicos refleja el aumento reciente de publicaciones de investigación de mecanismos celulares y moleculares

Mientras tanto, la responsabilidad permanece sobre el clínico para hacer el juicio terapéutico lo mejor posible.

Rincon, Fred, Patrick Lyden, and Stephan A Mayer. 2012. “Relationship Between Temperature, Hematoma Growth, and Functional Outcome After Intracerebral Hemorrhage.” Neurocritical Care (September 22). doi:10.1007/s12028-012-9779-9. http://www.ncbi.nlm.nih.gov/pubmed/23001769.

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