Episode 14: Intracerebral hemorrhage and elevated ICP (part 2)

The conclusion of our scenario of severe intraparenchymal hemorrhage with resulting herniation, with a closer look at neurological exams, prognostication, and the flow of care after initial stabilization, as well as our mindset as caregivers in these psychologically challenging cases.

Takeaway lessons

  1. Early tracheostomy may not hold concrete benefits for neuro patients (i.e. improved mortality), but it often facilitates practical goals such as earlier liberation from the ventilator, early mobilization, and earlier discharge to rehab, which do have tangible utility.
  2. Give frequent updates to family in cases of significant intracranial catastrophe. Avoid specific early prognostication unless the outcome is very obvious, but do emphasize poor prognostic signs, the importance of patience and endurance, and the likely quality of life given the available data.
  3. Altered mental status is not always a contraindication to extubation in the persistently neuro-injured patient, although some such patients will indeed have difficulty protecting their airways.
  4. These patients do improve, often after their ICU stay. Post-ICU follow-up is helpful to remind us of this, and when not possible, it’s good to simply remember that the ICU courses we perceive don’t always reflect eventual recovery.


Nestor MA, Boling B. Reversing Direct Oral Anticoagulants in Acute Intracranial Hemorrhage. Crit Care Nurse. 2019 39 (3): e1–e8.

ENLS Intracranial Hypertension and Herniation Protocol

ICH score

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