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Semin Neurol 2016; 36(03): 225-232
DOI: 10.1055/s-0036-1581991
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Critical Care Management of Intracerebral Hemorrhage

Adeolu O. Morawo
1   Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University, New Haven, Connecticut
,
Emily J. Gilmore
1   Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University, New Haven, Connecticut
› Author Affiliations
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Publication History

Publication Date:
23 May 2016 (online)

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Abstract

Spontaneous intracerebral hemorrhage (ICH), the most devastating and debilitating form of stroke, remains a major healthcare concern all over the world. Intracerebral hemorrhage is frequently managed in critical care settings where intensive monitoring and treatment are employed to prevent and address primary and secondary brain injury as well as other medical complications that may arise. Although there has been increasing data guiding the management of ICH in the past decade, prognosis remains dismal. In this article, the authors discuss the risk factors for ICH, the role of imaging, the major targets of neurocritical care management, the etiology and management of raised intracranial pressure, as well as prevention of and prompt response to the emergence of medical complications. They also discuss the effect of early withdrawal of life-sustaining therapy on prognosis. Finally, we outline several clinical trials that hold promise in improving our management of ICH in the near future.

Keywords

intracerebral hemorrhage - stroke - critical care neurology
 

  • References

  • 1 Gioia LC, Kate M, Dowlatshahi D, Hill MD, Butcher K. Blood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies. Curr Opin Crit Care 2015; 21 (2) 99-106
    CrossrefPubMedGoogle Scholar
  • 2 Poon MT, Fonville AF, Al-Shahi Salman R. Long-term prognosis after intracerebral haemorrhage: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2014; 85 (6) 660-667
    CrossrefPubMedGoogle Scholar
  • 3 Feigin VL, Krishnamurthi RV, Parmar P , et al; GBD 2013 Writing Group; GBD 2013 Stroke Panel Experts Group. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology 2015; 45 (3) 161-176
    CrossrefPubMedGoogle Scholar
  • 4 Hemphill III JC, Greenberg SM, Anderson CS , et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46 (7) 2032-2060
    CrossrefPubMedGoogle Scholar
  • 5 Mendelow AD, Gregson BA, Fernandes HM , et al; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005; 365 (9457) 387-397
    CrossrefPubMedGoogle Scholar
  • 6 Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM ; STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013; 382 (9890) 397-408
    CrossrefPubMedGoogle Scholar
  • 7 Mayer SA, Brun NC, Begtrup K , et al; FAST Trial Investigators. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2008; 358 (20) 2127-2137
    CrossrefPubMedGoogle Scholar
  • 8 Qureshi AI, Majidi S, Gilani WI , et al; Antihypertensive Treatment of Acute Cerebral Hemorrhage Study Investigators. Increased brain volume among good grade patients with intracerebral hemorrhage. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) study. Neurocrit Care 2014; 20 (3) 470-475
    CrossrefPubMedGoogle Scholar
  • 9 Wang X, Arima H, Heeley E , et al; INTERACT2 Investigators. Magnitude of blood pressure reduction and clinical outcomes in acute intracerebral hemorrhage: intensive blood pressure reduction in acute cerebral hemorrhage trial study. Hypertension 2015; 65 (5) 1026-1032
    CrossrefPubMedGoogle Scholar
  • 10 Yeatts SD, Palesch YY, Moy CS, Selim M. High dose deferoxamine in intracerebral hemorrhage (HI-DEF) trial: rationale, design, and methods. Neurocrit Care 2013; 19 (2) 257-266
    CrossrefPubMedGoogle Scholar
  • 11 ClinicalTrials.gov. Intracerebral Hemorrhage Deferoxamine Trial. Available at: https://clinicaltrials.gov/ct2/show/NCT02175225?term=iDEF&rank=1 . Accessed November 30, 2015
    PubMedGoogle Scholar
  • 12 Barnes B, Hanley DF, Carhuapoma JR. Minimally invasive surgery for intracerebral haemorrhage. Curr Opin Crit Care 2014; 20 (2) 148-152
    CrossrefPubMedGoogle Scholar
  • 13 Ziai WC, Tuhrim S, Lane K , et al; CLEAR III Investigators. A multicenter, randomized, double-blinded, placebo-controlled phase III study of Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III). Int J Stroke 2014; 9 (4) 536-542
    CrossrefPubMedGoogle Scholar
  • 14 Witsch J, Bruce E, Meyers E , et al. Intraventricular hemorrhage expansion in patients with spontaneous intracerebral hemorrhage. Neurology 2015; 84 (10) 989-994
    CrossrefPubMedGoogle Scholar
  • 15 Chan S, Hemphill III JC. Critical care management of intracerebral hemorrhage. Crit Care Clin 2014; 30 (4) 699-717
    CrossrefPubMedGoogle Scholar
  • 16 Rincon F, Mayer SA. Clinical review: critical care management of spontaneous intracerebral hemorrhage. Crit Care 2008; 12 (6) 237
    CrossrefPubMedGoogle Scholar
  • 17 Goldstein JN, Gilson AJ. Critical care management of acute intracerebral hemorrhage. Curr Treat Options Neurol 2011; 13 (2) 204-216
    Google Scholar
  • 18 Mehndiratta P, Manjila S, Ostergard T , et al. Cerebral amyloid angiopathy-associated intracerebral hemorrhage: pathology and management. Neurosurg Focus 2012; 32 (4) E7
    PubMedGoogle Scholar
  • 19 Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol 2012; 60 (9) 861-867
    CrossrefPubMedGoogle Scholar
  • 20 Jauch EC, Pineda JA, Claude Hemphill J. Emergency neurological life support: intracerebral hemorrhage. Neurocrit Care 2015; 23 (Suppl. 02) 83-93
    CrossrefPubMedGoogle Scholar
  • 21 Jones EM, Boehme AK, Aysenne A , et al. Prolonged emergency department length of stay as a predictor of adverse outcomes in patients with intracranial hemorrhage. J Crit Care Med 2015; 2015 (2015) 2015
    PubMedGoogle Scholar
  • 22 Kranz PG, Amrhein TJ, Provenzale JM. Spontaneous brain parenchymal hemorrhage: an approach to imaging for the emergency room radiologist. Emerg Radiol 2015; 22 (1) 53-63
    CrossrefPubMedGoogle Scholar
  • 23 Fink KR, Benjert JL. Imaging of nontraumatic neuroradiology emergencies. Radiol Clin North Am 2015; 53 (4) 871-890 , x
    CrossrefPubMedGoogle Scholar
  • 24 Wilson D, Adams ME, Robertson F, Murphy M, Werring DJ. Investigating intracerebral haemorrhage. BMJ 2015; 350: h2484
    CrossrefPubMedGoogle Scholar
  • 25 Manno EM. Update on intracerebral hemorrhage. Continuum (Minneap Minn) 2012; 18 (3) 598-610
    PubMedGoogle Scholar
  • 26 Anderson CS, Qureshi AI. Implications of INTERACT2 and other clinical trials: blood pressure management in acute intracerebral hemorrhage. Stroke 2015; 46 (1) 291-295
    CrossrefPubMedGoogle Scholar
  • 27 Kuramatsu JB, Gerner ST, Schellinger PD , et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 2015; 313 (8) 824-836
    CrossrefPubMedGoogle Scholar
  • 28 Qureshi AI, Palesch YY. Antihypertensive treatment of acute cerebral hemorrhage (ATACH) II: design, methods, and rationale. Neurocrit Care 2011; 15 (3) 559-576
    CrossrefPubMedGoogle Scholar
  • 29 Li Q, Huang YJ, Zhang G , et al. Intraventricular hemorrhage and early hematoma expansion in patients with intracerebral hemorrhage. Sci Rep 2015; 5: 11357
    CrossrefPubMedGoogle Scholar
  • 30 Hanger HC, Geddes JA, Wilkinson TJ, Lee M, Baker AE. Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates. Intern Med J 2013; 43 (3) 308-316
    CrossrefPubMedGoogle Scholar
  • 31 Suzuki Y, Kitahara T, Soma K , et al. Impact of platelet transfusion on survival of patients with intracerebral hemorrhage after administration of anti-platelet agents at a tertiary emergency center. PLoS ONE 2014; 9 (5) e97328
    CrossrefPubMedGoogle Scholar
  • 32 Naidech AM, Liebling SM, Rosenberg NF , et al. Early platelet transfusion improves platelet activity and may improve outcomes after intracerebral hemorrhage. Neurocrit Care 2012; 16 (1) 82-87
    CrossrefPubMedGoogle Scholar
  • 33 Martin M, Conlon LW. Does platelet transfusion improve outcomes in patients with spontaneous or traumatic intracerebral hemorrhage?. Ann Emerg Med 2013; 61 (1) 58-61
    CrossrefPubMedGoogle Scholar
  • 34 Hagii J, Tomita H, Metoki N , et al. Characteristics of intracerebral hemorrhage during rivaroxaban treatment: comparison with those during warfarin. Stroke 2014; 45 (9) 2805-2807
    CrossrefPubMedGoogle Scholar
  • 35 Saji N, Kimura K, Aoki J, Uemura J, Sakamoto Y. Intracranial Hemorrhage Caused by Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)- Multicenter Retrospective Cohort Study in Japan. Circ J 2015; 79 (5) 1018-1023
    CrossrefPubMedGoogle Scholar
  • 36 Sarode R, Milling Jr TJ, Refaai MA , et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation 2013; 128 (11) 1234-1243
    CrossrefPubMedGoogle Scholar
  • 37 Steiner T, Freiberger A, Griebe M , et al. International normalised ratio normalisation in patients with coumarin-related intracranial haemorrhages—the INCH trial: a randomised controlled multicentre trial to compare safety and preliminary efficacy of fresh frozen plasma and prothrombin complex—study design and protocol. Int J Stroke 2011; 6 (3) 271-277
    Google Scholar
  • 38 Leissinger CA, Blatt PM, Hoots WK, Ewenstein B. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol 2008; 83 (2) 137-143
    CrossrefPubMedGoogle Scholar
  • 39 Dickneite G, Hoffman M. Reversing the new oral anticoagulants with prothrombin complex concentrates (PCCs): what is the evidence?. Thromb Haemost 2014; 111 (2) 189-198
    PubMedGoogle Scholar
  • 40 Yasaka M. New Insights into Nonvitamin K Antagonist Oral Anticoagulants' Reversal of Intracerebral Hemorrhage. Front Neurol Neurosci 2015; 37: 93-106
    PubMedGoogle Scholar
  • 41 Praxbind® (idarucizumab) Injection, 2.5 g/50 mL. 2015. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2015/761025Orig1s000ltr.pdf . Accessed December 7, 2015
    PubMedGoogle Scholar
  • 42 Pollack Jr CV, Reilly PA, Eikelboom J , et al. Idarucizumab for dabigatran reversal. N Engl J Med 2015; 373 (6) 511-520
    CrossrefPubMedGoogle Scholar
  • 43 Portola Pharmaceuticals, Inc Andexanet alfa: FXa inhibitor antidote. 2015 available at: https://www.portola.com/clinical-development/andexanet-alfa-fxa-inhibitor-antidote/ . Accessed April 12, 2016
    PubMedGoogle Scholar
  • 44 Siegal DM, Curnutte JT, Connolly SJ , et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. N Engl J Med 2015; 373 (25) 2413-2424
    CrossrefPubMedGoogle Scholar
  • 45 Yates S, Sarode R. Reversal of anticoagulant effects in patients with intracerebral hemorrhage. Curr Neurol Neurosci Rep 2015; 15 (1) 504
    CrossrefPubMedGoogle Scholar
  • 46 Tazarourte K, Riou B, Tremey B, Samama CM, Vicaut E, Vigué B ; EPAHK study group. Guideline-concordant administration of prothrombin complex concentrate and vitamin K is associated with decreased mortality in patients with severe bleeding under vitamin K antagonist treatment (EPAHK study). Crit Care 2014; 18 (2) R81
    CrossrefPubMedGoogle Scholar
  • 47 Okada T, Nakase T, Sasaki M, Ishikawa T. Do the antithrombotic therapy at the time of intracerebral hemorrhage influence clinical outcome? Analysis between the difference of antiplatelet and anticoagulant agents and clinical course. J Stroke Cerebrovasc Dis 2014; 23 (7) 1781-1788
    CrossrefPubMedGoogle Scholar
  • 48 Falcone GJ, Rosand J. Aspirin should be discontinued after lobar intracerebral hemorrhage. Stroke 2014; 45 (10) 3151-3152
    CrossrefPubMedGoogle Scholar
  • 49 Al-Shahi Salman R, Dennis MS. Antiplatelet therapy may be continued after intracerebral hemorrhage. Stroke 2014; 45 (10) 3149-3150
    CrossrefPubMedGoogle Scholar
  • 50 Naidech AM, Maas MB, Levasseur-Franklin KE , et al. Desmopressin improves platelet activity in acute intracerebral hemorrhage. Stroke 2014; 45 (8) 2451-2453
    CrossrefPubMedGoogle Scholar
  • 51 Keep RF, Hua Y, Xi G. Intracerebral haemorrhage: mechanisms of injury and therapeutic targets. Lancet Neurol 2012; 11 (8) 720-731
    CrossrefPubMedGoogle Scholar
  • 52 Mould WA, Carhuapoma JR, Muschelli J , et al; MISTIE Investigators. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013; 44 (3) 627-634
    CrossrefPubMedGoogle Scholar
  • 53 Wang X, Arima H, Al-Shahi Salman R , et al; INTERACT Investigators. Clinical prediction algorithm (BRAIN) to determine risk of hematoma growth in acute intracerebral hemorrhage. Stroke 2015; 46 (2) 376-381
    CrossrefPubMedGoogle Scholar
  • 54 Dowlatshahi D, Demchuk AM, Flaherty ML, Ali M, Lyden PL, Smith EE ; VISTA Collaboration. Defining hematoma expansion in intracerebral hemorrhage: relationship with patient outcomes. Neurology 2011; 76 (14) 1238-1244
    CrossrefPubMedGoogle Scholar
  • 55 Huynh TJ, Aviv RI, Dowlatshahi D , et al; PREDICT/Sunnybrook CTA Investigators. Validation of the 9-point and 24-point hematoma expansion prediction scores and derivation of the PREDICT A/B scores. Stroke 2015; 46 (11) 3105-3110
    CrossrefPubMedGoogle Scholar
  • 56 Barras CD, Tress BM, Christensen S , et al; Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators. Quantitative CT densitometry for predicting intracerebral hemorrhage growth. AJNR Am J Neuroradiol 2013; 34 (6) 1139-1144
    CrossrefPubMedGoogle Scholar
  • 57 Murthy SB, Moradiya Y, Dawson J, Lees KR, Hanley DF, Ziai WC ; VISTA-ICH Collaborators. Perihematomal edema and functional outcomes in intracerebral hemorrhage: influence of hematoma volume and location. Stroke 2015; 46 (11) 3088-3092
    CrossrefPubMedGoogle Scholar
  • 58 Sansing LH, Messe SR, Cucchiara BL, Lyden PD, Kasner SE. Anti-adrenergic medications and edema development after intracerebral hemorrhage. Neurocrit Care 2011; 14 (3) 395-400
    CrossrefPubMedGoogle Scholar
  • 59 Chan E, Anderson CS, Wang X , et al; INTERACT2 Investigators. Significance of intraventricular hemorrhage in acute intracerebral hemorrhage: intensive blood pressure reduction in acute cerebral hemorrhage trial results. Stroke 2015; 46 (3) 653-658
    CrossrefPubMedGoogle Scholar
  • 60 Ovesen C, Christensen AF, Havsteen I , et al. Prediction and prognostication of neurological deterioration in patients with acute ICH: a hospital-based cohort study. BMJ Open 2015; 5 (7) e008563
    CrossrefPubMedGoogle Scholar
  • 61 Maas MB, Nemeth AJ, Rosenberg NF, Kosteva AR, Prabhakaran S, Naidech AM. Delayed intraventricular hemorrhage is common and worsens outcomes in intracerebral hemorrhage. Neurology 2013; 80 (14) 1295-1299
    CrossrefPubMedGoogle Scholar
  • 62 Provencio JJ, Da Silva IR, Manno EM. Intracerebral hemorrhage: new challenges and steps forward. Neurosurg Clin N Am 2013; 24 (3) 349-359
    CrossrefPubMedGoogle Scholar
  • 63 Rincon F, Patel U, Schorr C , et al. Brain injury as a risk factor for fever upon admission to the intensive care unit and association with in-hospital case fatality: a matched cohort study. J Intensive Care Med 2015; 30 (2) 107-114
    CrossrefPubMedGoogle Scholar
  • 64 Leira R, Dávalos A, Silva Y , et al; Stroke Project, Cerebrovascular Diseases Group of the Spanish Neurological Society. Early neurologic deterioration in intracerebral hemorrhage: predictors and associated factors. Neurology 2004; 63 (3) 461-467
    CrossrefPubMedGoogle Scholar
  • 65 Lord AS, Gilmore E, Choi HA, Mayer SA ; VISTA-ICH Collaboration. Time course and predictors of neurological deterioration after intracerebral hemorrhage. Stroke 2015; 46 (3) 647-652
    CrossrefPubMedGoogle Scholar
  • 66 Rincon F, Lyden P, Mayer SA. Relationship between temperature, hematoma growth, and functional outcome after intracerebral hemorrhage. Neurocrit Care 2013; 18 (1) 45-53
    CrossrefPubMedGoogle Scholar
  • 67 Steiner T, Al-Shahi Salman R, Beer R , et al; European Stroke Organisation. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014; 9 (7) 840-855
    CrossrefPubMedGoogle Scholar
  • 68 Béjot Y, Aboa-Eboulé C, Hervieu M , et al. The deleterious effect of admission hyperglycemia on survival and functional outcome in patients with intracerebral hemorrhage. Stroke 2012; 43 (1) 243-245
    CrossrefPubMedGoogle Scholar
  • 69 Tapia-Pérez JH, Gehring S, Zilke R, Schneider T. Effect of increased glucose levels on short-term outcome in hypertensive spontaneous intracerebral hemorrhage. Clin Neurol Neurosurg 2014; 118: 37-43
    CrossrefPubMedGoogle Scholar
  • 70 Wu YT, Li TY, Lu SC , et al. Hyperglycemia as a predictor of poor outcome at discharge in patients with acute spontaneous cerebellar hemorrhage. Cerebellum 2012; 11 (2) 543-548
    CrossrefPubMedGoogle Scholar
  • 71 Tan X, He J, Li L , et al. Early hyperglycaemia and the early-term death in patients with spontaneous intracerebral haemorrhage: a meta-analysis. Intern Med J 2014; 44 (3) 254-260
    CrossrefPubMedGoogle Scholar
  • 72 Qureshi AI, Palesch YY, Martin R , et al; ATACH Investigators. Association of serum glucose concentrations during acute hospitalization with hematoma expansion, perihematomal edema, and three month outcome among patients with intracerebral hemorrhage. Neurocrit Care 2011; 15 (3) 428-435
    CrossrefPubMedGoogle Scholar
  • 73 Gilmore E, Choi HA, Hirsch LJ, Claassen J. Seizures and CNS hemorrhage: spontaneous intracerebral and aneurysmal subarachnoid hemorrhage. Neurologist 2010; 16 (3) 165-175
    CrossrefPubMedGoogle Scholar
  • 74 Claassen J, Taccone FS, Horn P, Holtkamp M, Stocchetti N, Oddo M ; Neurointensive Care Section of the European Society of Intensive Care Medicine. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 2013; 39 (8) 1337-1351
    CrossrefPubMedGoogle Scholar
  • 75 Naidech AM, Garg RK, Liebling S , et al. Anticonvulsant use and outcomes after intracerebral hemorrhage. Stroke 2009; 40 (12) 3810-3815
    CrossrefPubMedGoogle Scholar
  • 76 Sheth KN, Martini SR, Moomaw CJ , et al; ERICH Investigators. Prophylactic antiepileptic drug use and outcome in the ethnic/racial variations of intracerebral hemorrhage study. Stroke 2015; 46 (12) 3532-3535
    CrossrefPubMedGoogle Scholar
  • 77 Fisher RS, Acevedo C, Arzimanoglou A , et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014; 55 (4) 475-482
    CrossrefPubMedGoogle Scholar
  • 78 Morgenstern LB, Zahuranec DB, Sánchez BN , et al. Full medical support for intracerebral hemorrhage. Neurology 2015; 84 (17) 1739-1744
    CrossrefPubMedGoogle Scholar
  • 79 Gilmore EJ, Sheth KN. Improving ascertainment and communication of prognosis in intracerebral hemorrhage. Crit Care 2013; 17 (6) 1021
    CrossrefPubMedGoogle Scholar
  • 80 Souter MJ, Blissitt PA, Blosser S , et al. Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management : A Position Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2015; 23 (1) 4-13
    CrossrefPubMedGoogle Scholar
  • 81 Gladstone DJ. “Spot sign” selection of intracerebral hemorrhage to guide hemostatic therapy. Available at: https://clinicaltrials.gov/ct2/show/NCT01359202?term=SPOTLIGHT&rank=1 . Accessed November 30, 2015
    PubMedGoogle Scholar
  • 82 Bressan JLS. Decompressive hemicraniectomy in intracerebral hemorrhage. Available at: https://clinicaltrials.gov/ct2/show/NCT02258919?term=SWITCH+AND+%22Hemorrhage%22&rank=1 . Accessed November 30, 2015
    PubMedGoogle Scholar