 Initial fenoldopam doses in range of 0.01 to 0.3 mcg/kg per minute have been described. References: 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension 2018; 71:e140-e144]. Hypertension 2018; 71:e13-e115. 2. Marik PE, Varon J. Hypertensive crises: Challenges and management. Chest 2007; 131:1949. 3. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42:1206. 4. Varon J. Treatment of acute severe hypertension: Current and newer agents. Drugs 2008; 68:283. Graphic 64066 Version 36.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 52/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Management of intracranial pressure for patients with acute intracerebral hemorrhage* ICH: intracerebral hemorrhage; ICP: intracranial pressure. For patients with ICH without premorbid advanced directives specifying limitations of invasive care. Hemostatic and blood pressure issues should be addressed simultaneously. Refer to the UpToDate topic for additional details. Maintain midline head position, avoid internal jugular catheters, and avoid tight device securement (eg, device ties, endotracheal tube holder, or intravenous line dressings). Graphic 132294 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 53/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Richmond Agitation-Sedation Scale (RASS) Score Term Description +4 Combative Overtly combative or violent, immediate danger to staff +3 Very agitated Pulls on or removes tubes or catheters, aggressive behavior toward staff +2 Agitated Frequent nonpurposeful movement or patient-ventilator dyssynchrony +1 Restless Anxious or apprehensive but movements not aggressive or vigorous 0 Alert and calm 1 Drowsy Not fully alert, sustained (>10 seconds) awakening, eye contact to voice 2 Light sedation Briefly (<10 seconds) awakens with eye contact to voice 3 Moderate sedation Any movement (but no eye contact) to voice 4 Deep sedation No response to voice, any movement to physical stimulation 5 Unarousable No response to voice or physical stimulation Procedure 1. Observe patient. Is patient alert and calm (score 0)? 2. Does patient have behavior that is consistent with restlessness or agitation? Assign score +1 to +4 using the criteria listed above. 3. If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker. Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1). Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2). Patient has any movement in response to voice, excluding eye contact (score -3). 4. If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response. Patient has any movement to physical stimulation (score -4). Patient has no response to voice or physical stimulation (score -5). Reproduced with permission from: Sessler C, Gosnell M, Grap MJ, et al. The Richmond agitation-sedation scale. Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166:1338. Copyright 2002 American https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 54/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Thoracic Society. Graphic 57874 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 55/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Clinical progression of transtentorial herniation Headache Altered level of consciousness Dilation of ipsilateral pupil Cranial nerve III palsy Ptosis Loss of medial gaze Decerebrate posturing Hemiparesis Dilation of opposite pupil Alteration of respiration Bradycardia Hypertension Respiratory arrest Graphic 70683 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 56/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Glasgow Coma Scale (GCS) Score Eye opening Spontaneous 4 Response to verbal command 3 Response to pain 2 No eye opening 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localizing response to pain 5 Withdrawal response to pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Total The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. Graphic 81854 Version 9.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 57/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Transtentorial herniation Data from: Plum F, Posner JB. The Diagnosis of Stupor and Coma III. FA Davis, Philadelphia 1995. p. 103. Graphic 76974 Version 5.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 58/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Pharmacologic properties of antiseizure medications Enzyme or Metabolism and Protein binding Half-lif transporter clearance (%) adults (h induction/inhibition* 20 Brivaracetam Metabolized Inhibits epoxide 9 primarily by CYP- independent hydroxylase hydrolysis (60%) and CYP2C19 (30%) Dose adjustment is needed in hepatic impairment Cannabidiol Hepatic (primarily) and gut by CYP2C19, CYP3A4, UGT1A7, UGT1A9, and UGT2B7 to Inhibits BCRP/ABCG2, BSEP/ABCB11, CYP2C19 (moderate) >94 56 to 61 May increase serum concentration of clobazam and the active metabolite(s) of clobazam active metabolite 7- OH-CBD and then to inactive metabolite 7-COOH-CBD Dose adjustment is needed in moderate to severe hepatic impairment Carbamazepine >90% metabolized by CYPs 3A4 (major) Potent and broad- spectrum inducer of CYP, 75 25 to 65 (init enzyme-ind and 1A2/2C8 (minor) to active (epoxide) UGT-glucuronidation, and P-gp naive patien 8 to 22 (afte and inactive weeks due t induction) metabolites Dose adjustment is needed in severe renal impairment; use is not recommended in moderate or severe hepatic impairment Cenobamate Primarily May increase serum 60 50 to 60 hou metabolized by glucuronidation via concentrations of clobazam, phenobarbital, https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 59/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate UGT2B7 and to a phenytoin, and CYP2C19 lesser extent by substrates UGT2B4, and by oxidation via May decrease serum concentrations of carbamazepine, CYP2E1, CYP2A6, CYP2B6, and to a lamotrigine, and CYP2B6 lesser extent by CYP2C19 and and CYP3A substrates CYP3A4/5 Dose adjustment is needed for hepatic impairment; not recommended for patients with severe hepatic impairment or end-stage renal disease Clobazam >90% metabolized by CYPs 3A4, 2C19, 2B6 and non-CYP transformations to active (N- Inhibits CYP2D6 (weak) 80 to 90 (clobazam, parent drug) 36 to 42 (clo parent drug 70 (N- 71 to 82 (N- desmethylclobazam, active metabolite) desmethylcl active metab desmethylclobazam) and inactive metabolites Active metabolite is primarily metabolized by CYP2C19 Dose adjustment is needed in hepatic impairment Eslicarbazepine Prodrug; <33% of active form Induces CYP3A4 (moderate) <40 13 to 20 (pro in renal undergoes UGT- insufficiency Inhibits CYP2C19 (weak) glucuronidation (including <5% metabolized to oxcarbazepine); 66% is excreted renally as unchanged drug Dose adjustment is needed for renal impairment; not https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 60/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate recommended in patients with severe hepatic impairment Ethosuximide ~80% metabolized by CYP3A4 (major) None <5 40 to 60 and non-CYP transformations to inactive metabolites Felbamate 50% metabolized by Increases conversion of 25 13 to 22 (pro CYPs 3A4, 2E1 (minor); ~50% renally excreted as carbamazepine to active epoxide metabolite; mechanism not in renal insufficiency unchanged drug established Dose adjustment is Inhibits CYP2C19 (weak) needed in renal impairment Gabapentin >95% renally None <5 5 to 7 (prolo excreted as unchanged drug (ie, does not undergo hepatic metabolism) renal insuffi >130 hours anuria) Dose adjustment is needed in renal impairment Lacosamide 40% renally excreted as unchanged drug; 30% metabolized by non-CYP transformations None <15 13 (including methylation) to inactive metabolite Dose adjustment is needed in hepatic and renal impairment Lamotrigine >90% metabolized by UGT- May induce its own metabolism by UGT- 55 12 to 62 glucuronidation and other non-CYP glucuronidation (minor) transformations to inactive metabolites https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 61/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Dose adjustment is needed in moderate to severe renal or hepatic impairment Levetiracetam >65% renally None <10 6 to 8 excreted as unchanged drug; 24% metabolized by non-CYP transformation (including amidase hydrolysis) to inactive metabolites Dose adjustment is needed in renal impairment Oxcarbazepine Prodrug; 70% of Induces CYP3A4 (weak) 40 9 (active me active (MHD) form undergoes UGT- glucuronidation; 30% is renally excreted as unchanged active drug and UGT-glucuronidation but does not induce its own metabolism prolonged in insufficiency Dose adjustment is needed in severe renal impairment Perampanel >70% metabolized Appears to induce 95 105 by CYPs 3A4, 3A5 and non-CYP transformations to metabolism of progestin- containing hormonal contraceptives inactive metabolites Dose adjustment is needed in mild or moderate hepatic impairment Phenobarbital 75% metabolized by Potent and broad- 55 75 to 110 CYPs 2C19, 2C9 (minor) and spectrum inducer of CYP and UGT-glucuronidation glucosidase hydrolysis and 2E1 (minor) to inactive metabolites; 25% https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 62/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate excreted renally as unchanged drug Dose adjustment is needed in severe renal or hepatic impairment Phenytoin >90% metabolized Potent and broad- 90 to 95 9 to >42 (do by CYPs 2C9, 2C19, 3A4 (minor) and spectrum inducer of CYP and UGT-glucuronidation dependent) non-CYP transformations to inactive metabolites; clearance is dose dependent, saturable, and may be subject to genetic polymorphism Dose adjustment is needed in severe renal or hepatic insufficiency; monitoring of free (unbound) concentrations also suggested Pregabalin >95% excreted None <5 6 renally as unchanged drug Dose adjustment is needed in renal impairment Primidone 75% metabolized by CYPs 2C19, 2C9 Potent and broad- spectrum inducer of CYP 0 to 20 10 to 15 (pa 29 to 100 (ac (minor) and 2E1 metabolite) (minor) to active intermediates; ~25% excreted renally as unchanged drug Dose adjustment is needed in moderate and severe renal or hepatic impairment; https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 63/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate close monitoring of plasma levels suggested Rufinamide >90% metabolized by non-CYP Induces CYP3A4 (weak) 35 6 to 10 transformations (hydrolysis) to inactive metabolites Stiripentol Metabolized Inhibits CYP3A4, 99 4.5 to 13 primarily in the liver by CYP450 enzymes CYP2C19, CYP3A4, CYP2C19, P-gp, and BCRP and glucuronidation Tiagabine >90% metabolized None 95 7 to 9 by CYP3A4 and non- CYP transformations to inactive metabolites 2 to 5 (with inducing an medications Topiramate >65% excreted renally as unchanged drug; None 9 to 17 12 to 24 <30% metabolized by non-CYP transformations to inactive metabolites; extent of metabolism is increased ~50% in patients receiving enzyme-inducing antiseizure medications Dose adjustment is needed in moderate and severe renal or hepatic impairment Valproate >95% undergoes None 80 to 95 7 to 16 complex transformations including CYPs 2C9, 2C19, 2A6, UGT- glucuronidation and other non-CYP transformation https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 64/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Dose adjustment is needed in hepatic impairment Vigabatrin >90% excreted renally as None 0 5 to 13 (unre duration of unchanged drug Dose adjustment is needed in renal impairment Zonisamide >65% metabolized None 50 63 by CYPs 3A4, 2C19 (minor) and non- CYP transformations Dose adjustment and/or slower titration is needed in mild renal impairment or hepatic impairment; not recommended in patients with moderate or severe renal impairment CYP: cytochrome P450; MHD: monohydroxy derivative active form of oxcarbazepine; P-gp: membrane P-glycoprotein multidrug resistance transporter; UGT-glucuronidation: metabolism by uridine 5'diphosphate-glucuronyltransferases. The inhibitors and inducers of CYP or UGT drug metabolism and P-gp transporters listed in this table can alter serum concentrations of drugs that are dependent upon these enzymes or transporters for elimination, activation, or bioavailability. Classifications are based on US Food and Drug Administration guidance [4, 5]. Other sources may use a different classification system resulting in some agents being classified differently. Specific interactions should be assessed using a drug interaction program such as Lexicomp interactions included within UpToDate. Highly protein-bound antiseizure medications exhibit altered pharmacokinetics, including greater therapeutic and toxic effects and drug interactions, when given in usual doses to patients with low serum albumin or protein-binding affinity (eg, due to nephrotic syndrome or acidosis). Dose alteration is needed and monitoring of unbound (free) antiseizure medication serum concentrations is suggested. Refer to UpToDate topic for additional information. Inhibitors of epoxide hydroxylase (eg, brivaracetam) can decrease metabolism of phenytoin and active metabolite of carbamazepine; refer to UpToDate topic. Data from: Lexicomp Online. Copyright 1978-2023 Lexicomp, Inc. All Rights Reserved. Additional data from: https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 65/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 1. Bazil CW. Antiepileptic drugs in the 21st century. CNS Spectr 2001; 6:756. 2. Lacerda G, Krummel T, Sabourdy C, et al. Optimizing therapy of seizures in patients with renal or hepatic dysfunction. Neurology 2006; 67:S28. 3. Anderson GD, Hakimian S. Pharmacokinetic of antiepileptic drugs in patients with hepatic or renal impairment. Clin Pharmacokinet 2014; 53:29. 4. US Food and Drug Administration. Clinical drug interaction studies Cytochrome P450 enzyme- and transporter- mediated drug interactions guidance for industry, January 2020. Available at: https://www.fda.gov/regulatory- information/search-fda-guidance-documents/clinical-drug-interaction-studies-cytochrome-p450-enzyme-and- transporter-mediated-drug-interactions (Accessed on June 5, 2020). 5. US Food & Drug Administration. Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers. Available at: https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug- interactions-table-substrates-inhibitors-and-inducers (Accessed on June 12, 2019). Graphic 60182 Version 35.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 66/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Modified Rankin Scale Score Description 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 Dead Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604. Copyright 1988 Lippincott Williams & Wilkins. Graphic 75411 Version 13.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 67/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate CT angiography "spot sign" Patient with spot sign, demonstrating extravasation and hematoma expansion. CT slice selection has been optimized for hematoma configuration, not for head position. (A) Unenhanced CT demonstrates left posterior putaminal and internal capsule hematoma with mild surrounding edema. An old parieto-occipital infarct is seen posterior to this. (B) A small focus of enhancement is seen peripherally on CTA source images, consistent with the spot sign (arrow). https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 68/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate (C) Post-contrast CT demonstrates enlargement of the spot sign, consistent with extravasation (thick arrow). (D) Unenhanced CT image one day after presentation reveals hematoma enlargement and intraventricular hemorrhage. CT: computed tomography; CTA: computed tomography angiography. From: Wada R, Aviv RI, Fox AJ, et al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 2007; 38:1257. Copyright 2007 American Heart Association, Inc. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 118220 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 69/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate ICH features on head CT associated with the risk of hematoma expansion Noncontrast head CT showing acute ICH with signs associated with the risk of subsequent hematoma expansion: irregular shape (A), island sign (B; arrow), hypodensity (C; dashed arrow), heterogeneity (D), black hole sign (E; thick arrow), swirl sign (F), and blend sign (G; arrowhead). ICH: intracerebral hemorrhage; CT: computed tomography. Courtesy of Glenn A Tung, MD, FACR. Graphic 132280 Version 1.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 70/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate ICH score to predict 30-day mortality after spontaneous ICH Component ICH score points GCS score* at presentation 3 to 4 2 5 to 12 1 13 to 15 0 ICH volume on initial imaging 3 30 cm 1 3 <30 cm 0 Intraventricular extension of ICH Present 1 Absent 0 Infratentorial origin of ICH Yes 1 No 0 Age (years) 80 1 <80 0 Total 0 to 6 The ICH score results range from 0 to 6, with higher scores being associated with higher predicted mortality risk. The predicted 30 day mortality is 13% for an ICH score of 1, 26% for score of 2, 72% for a score of 3, 97% for a score of 4, and 100% for a score of 5. In the initial cohort, no patient with an ICH score of 0 died and none had a score of 6. ICH: intracerebral hemorrhage; GCS: Glasgow coma scale. Refer to the separate UpToDate table on Glasgow coma scale. From: From: Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32:891. DOI: 10.1161/01.str.32.4.891. Copyright 2001 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 132292 Version 2.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 71/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate National Institutes of Health Stroke Scale (NIHSS) Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (ie, repeated requests to patient to make a special effort). Instructions Scale definition Score 1a. Level of consciousness: The 0 = Alert; keenly responsive. investigator must choose a response if a full 1 = Not alert; but arousable by minor stimulation to obey, answer, or respond. evaluation is prevented by such obstacles as an endotracheal tube, language barrier, 2 = Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped). orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement _____ (other than reflexive posturing) in response to noxious stimulation. 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. 1b. Level of consciousness questions: The 0 = Answers both questions correctly. patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from 1 = Answers one question correctly. 2 = Answers neither question correctly. _____ any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues. 1c. Level of consciousness commands: The 0 = Performs both tasks correctly. _____ patient is asked to open and close the eyes and then to grip and release the non-paretic 1 = Performs one task correctly. 2 = Performs neither task correctly. hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (ie, https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 72/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 2. Best gaze: Only horizontal eye movements will be tested. Voluntary or 0 = Normal. 1 = Partial gaze palsy; gaze is abnormal in reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If one or both eyes, but forced deviation or total gaze paresis is not present. the patient has a conjugate deviation of the 2 = Forced deviation, or total gaze paresis eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a not overcome by the oculocephalic maneuver. patient has an isolated peripheral nerve paresis (cranial nerves III, IV or VI), score a 1. Gaze is testable in all aphasic patients. _____ Patients with ocular trauma, bandages, pre- existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy. 3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, 0 = No visual loss. 1 = Partial hemianopia. 2 = Complete hemianopia. but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut 3 = Bilateral hemianopia (blind including cortical blindness). _____ asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 4. Facial palsy: Ask - or use pantomime to encourage - the patient to show teeth or 0 = Normal symmetrical movements. _____ 1 = Minor paralysis (flattened nasolabial raise eyebrows and close eyes. Score symmetry of grimace in response to noxious fold, asymmetry on smiling). 2 = Partial paralysis (total or near-total paralysis of lower face). stimuli in the poorly responsive or non- comprehending patient. If facial trauma/bandages, orotracheal tube, tape or https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 73/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate other physical barriers obscure the face, 3 = Complete paralysis of one or both sides these should be removed to the extent (absence of facial movement in the upper possible. and lower face). 5. Motor arm: The limb is placed in the appropriate position: extend the arms 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in degrees, drifts down to bed, but has some _____ effort against gravity. the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN), and clearly write 3 = No effort against gravity; limb falls. 4 = No movement. the explanation for this choice. UN = Amputation or joint fusion, explain:________________ 5a. Left arm 5b. Right arm 6. Motor leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The 0 = No drift; leg holds 30-degree position for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. _____ 3 = No effort against gravity; leg falls to bed immediately. record the score as untestable (UN), and clearly write the explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding 0 = Absent. _____ evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, 1 = Present in one limb. 2 = Present in two limbs. ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests UN = Amputation or joint fusion, explain:________________ are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 74/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal from noxious 0 = Normal; no sensory loss. 1 = Mild-to-moderate sensory loss; patient stimulus in the obtunded or aphasic patient. feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial Only sensory loss attributed to stroke is scored as abnormal and the examiner pain with pinprick, but patient is aware of should test as many body areas (arms [not being touched. hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, score of 2, "severe or total sensory loss," should only be given when a severe or total loss of sensation can be clearly and leg. _____ demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of 0 = No aphasia; normal. _____ information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes the items on the attached naming sheet and to read from the attached list of sentences. conversation about provided materials Comprehension is judged from responses here, as well as to all of the commands in difficult or impossible. For example, in conversation about provided materials, the preceding general neurological exam. If examiner can identify picture or naming card content from patient's response. visual loss interferes with the tests, ask the patient to identify objects placed in the 2 = Severe aphasia; all communication is through fragmentary expression; great need hand, repeat, and produce speech. The intubated patient should be asked to write. for inference, questioning, and guessing by the listener. Range of information that can The patient in a coma (item 1a=3) will automatically score 3 on this item. The be exchanged is limited; listener carries burden of communication. Examiner cannot examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 75/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate patient is mute and follows no one-step identify materials provided from patient commands. response. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be 0 = Normal. normal, an adequate sample of speech must be obtained by asking patient to read or 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty. repeat words from the attached list. If the patient has severe aphasia, the clarity of 2 = Severe dysarthria; patient's speech is so articulation of spontaneous speech can be rated. Only if the patient is intubated or has _____ slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric. other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an UN = Intubated or other physical barrier, explain:________________ explanation for this choice. Do not tell the patient why he or she is being tested. 11. Extinction and inattention (formerly 0 = No abnormality. neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. 2 = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space. _____ both sides, the score is normal. The presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. _____ Adapted from: Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non- neurologists in the context of a clinical trial. Stroke 1997; 28:307. Graphic 61698 Version 8.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 76/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate FUNC score to predict functional outcome at 90-days after spontaneous intracerebral hemorrhage Component FUNC score points 3 ICH volume, cm <30 4 30-60 2 >60 0 Age, years <70 2 70-79 1 80 0 ICH location Lobar 2 Deep 1 Infratentorial 0 GCS score* 9 2 8 0 Pre-ICH cognitive impairment No 1 Yes 0 Total FUNC score 0-11 The FUNC score results range from 0 to 11, with 0 being the worst and 11 the best. Points are given for favorable predictors of functional 90-day outcome. The predicted likelihood of favorable outcome was 0 percent for FUNC scores 0 to 4, 13 percent for scores 5 to 7, 42 percent for score of 8, 66 percent for scores 9 to 10, and 82 percent for a score of 11. GCS: Glasgow coma scale; ICH: intracerebral hemorrhage hemorrhage. GCS scored at presentation. From: Rost NS, Smith EE, Chang Y, et al. Prediction of Functional Outcome in Patients with Primary Intracerebral Hemorrhage: The FUNC score. Stroke 2008; 39:2304. DOI: 10.1161/STROKEAHA.107.512202. Reproduced with permission from Lippincott https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 77/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Williams & Wilkins. Copyright 2008 American Heart Association. Unauthorized reproduction of this material is prohibited. Graphic 97671 Version 5.0 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 78/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Contributor Disclosures Guy Rordorf, MD No relevant financial relationship(s) with ineligible companies to disclose. Colin McDonald, MD No relevant financial relationship(s) with ineligible companies to disclose. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Jonathan A Edlow, MD, FACEP No relevant financial relationship(s) with ineligible companies to disclose. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator-initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Glenn A Tung, MD, FACR No relevant financial relationship(s) with ineligible companies to disclose. Richard P Goddeau, Jr, DO, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 79/79