A 64-year-old woman is brought to the emergency department because of the sudden onset of a "thunderclap" headache, nausea, and vomiting that began 45 minutes ago. Her husband notes that she became progressively confused and developed weakness on the right side of her body shortly after the headache started. She has a history of poorly controlled hypertension. On physical examination, her blood pressure is 202/114 mmHg and her heart rate is 72/min. She is lethargic and follows simple commands only with her left hand. Neurological examination shows a dense right-sided hemiplegia. A non-contrast CT scan of the head reveals a large hyperdense area in the left putamen with mild midline shift but no signs of herniation.
Which of the following is the most appropriate next step in the management of this patient's blood pressure?
The correct answer is:
B) Intravenous labetalol
This patient has a spontaneous intracerebral hemorrhage (ICH), likely due to a hypertensive emergency. Putaminal location is classic for hypertensive ICH. In the acute management of ICH, rapid but controlled lowering of blood pressure is critical to limit hematoma expansion. For patients presenting with a systolic blood pressure (SBP) between 150 and 220 mmHg, the goal is typically to lower the systolic blood pressure (SBP) to approximately 140 mmHg using titratable intravenous agents such as labetalol or nicardipine.
Answer choice A: Intravenous dexamethasone, is incorrect. While steroids like dexamethasone are effective for reducing vasogenic edema associated with brain tumors or abscesses, they have no proven benefit in the management of cytotoxic edema or mass effect resulting from an acute intracerebral hemorrhage and may increase the risk of complications like infection and hyperglycemia.
Answer choice C: Intravenous mannitol, is incorrect. Mannitol is an osmotic diuretic used to acutely lower intracranial pressure (ICP) in patients showing clinical signs of herniation (e.g., pupillary changes, Cushing triad). While this patient has a midline shift, she does not yet show definitive signs of herniation, and aggressive blood pressure control is a higher immediate priority for preventing further bleeding.
Answer choice D: Oral nmodipine, is incorrect. Nimodipine is a calcium channel blocker specifically indicated for the prevention of vasospasm in patients with subarachnoid hemorrhage (SAH). It does not have a role in the management of spontaneous intraparenchymal hemorrhage.
Answer choice E: Platelet transfusion, is incorrect. Platelet transfusion is indicated for patients with ICH who have significant thrombocytopenia or those who were taking antiplatelet medications, though its benefit in the latter is controversial. There is no indication that this patient has a low platelet count or was taking antiplatelet therapy.
Key Learning Point
In the acute management of spontaneous intracerebral hemorrhage (ICH), the primary goal is to prevent hematoma expansion. This is achieved through rapid blood pressure control, typically targeting a systolic blood pressure of 140 mmHg using intravenous antihypertensive agents such as labetalol or nicardipine.
