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Intracerebral Hemorrhage

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Title: Intracerebral Hemorrhage


1
Intracerebral Hemorrhage
2
Marc Dorfman, MD, FACEP, MACPEM Residency
Program Director Resurrection Medical
CenterChicago, IL
Marc Dorfman, MD, FACEP, MACP
3
Case Presentation
  • 57 year old female
  • Sudden onset, severe headache
  • Took ASA for relief
  • Slurred speech
  • Collapsed

4
Physical Exam
  • T 99.4 P52 BP 195/99 RR13
  • Pupils-2 mm reactive
  • Neck-no JVD, bruits
  • CV-bradycardia, no murmur
  • Abd-bs, soft , nt/nd
  • Skin-warm and dry

5
Neurological Exam
  • Neurological exam
  • no gag reflex, withdraws to pain, 4 DTR

6
GCS
  • Eyes-1
  • Verbal-1
  • Motor-4

7
NIH Stroke Scale
NIH Stroke Scale
8
NIHSS Score
  • Stroke scale 25

9
CT Scan
10
Key Clinical Questions
  • What's the optimal ED management of a patient
    with ICH?
  • What are the goals of BP management?
  • Why is ICP important?
  • What are the optimal strategies for managing ICP?
  • What other treatment modalities are available to
    the ED physician?

11
Key Clinical Questions
  • Which ICH patient require surgery?
  • How does hemorrhage volume affect mortality?
  • What are the new therapies being tested for this
    disease process?

12
NY Times
13
Mission Statement
  • ICH is a cause of significant mortality and
    morbidity. Despite its established burden,
    considerably less investigative attention has
    been devoted to the study of ICH than other forms
    of stroke. Only a limited number of clinical
    studies have been performed to examine the
    surgical and medical managements of patients with
    ICH. No consistently efficacious strategies
    have been identified in such investigations.
    Management of ICH unfortunately remains
    heterogeneous across institutions, and continues
    to suffer from the lack of proven medical and
    surgical effectiveness.

Update on management of intracerebral hemorrhage
Neurosurgery Focus 15 2003 1-6
14
Algorithm
Qureshi A, Tuhrim S Spontaneous Intracerebral
Hemorrhage NEJM, Vol 344, No 19 May 10, 2001
1450-1460
15
Intracranial Hemorrhage
  • Diagnosis
  • Treatment
  • ICP
  • BP management
  • Medical management
  • Neurosurgical indications
  • New treatment modalities

16
ICH Epidemiology
  • 30 day mortality 30-40
  • 50 of these in first 48 hours
  • One-fifth of survivors are independent at 6
    months
  • 7000 operations annually in USA to remove blood

17
ICH Presentation
  • Hypertension (90)
  • Altered mental status (50)
  • Headache (40)
  • Seizures (6-7)

18
ICH Diagnosis
CT scan is the most effective tool in the ED
  • CT scan

CT scan is excellent for imaging blood
19
Clinical Case ED Rx
  • Patient starts to vomit
  • B/P 266/122
  • RSI
  • Lidocaine 100 mgs
  • Etomadate 20 mgs
  • Succinylcholine 100 mgs
  • Mannitol 150 ccs
  • Elevate Head of Bed
  • Hyperventilation to pCO2-30

20
Clinical Case ED Rx
  • Paralytics-Pancuronium 7 mg
  • BP management-Nipride
  • Steroids-Decadron 10 mgs

21
Initial ED Therapy
  • Resuscitation of the patient-regardless of ICP
  • Assume elevated ICP in head injury/altered MS
    patient
  • ABCs-as all good ED physician would do

22
Key Concept
  • Cerebral blood flow
  • 1. Intracranial pressure
  • Elevated when ICP gt20 mm Hg
  • 2. Cerebral perfusion pressure
  • CPPMAP-ICP
  • Maintain CPP gt 70 mm Hg
  • Example MAP 100, ICP 20
  • CPP in above example 80 mmHg

23
Increased ICP Risk
  • Intracranial Pressure (ICP) considered a major
    contributor to mortality when elevated
  • Correlation between elevated ICP and poor outcome
  • Increased risk of
  • Herniation
  • Decreased Cerebral perfusion

24
Increased ICP Treatment
  • Controlling ICP is considered essential
  • Osmotherapy
  • Hyperventilation
  • Barbiturate coma

25
Clinical ICP Assessment
  • For those without access to emergent ICP monitors
  • Pupils size and reactivity
  • Neurological status-deterioration vs. improvement

26
NIH Stroke Scale
NIH Stroke Scale
27
ICP Monitors
  • GCS less than 9
  • All patients whose condition is thought to be
    deteriorating due to elevated ICP

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
28
Osmotherapy
  • Osmotherapy-Mannitol
  • Reduces ICP by decreasing cerebral fluid volume
  • Rebound effect-use less than 5 days
  • Intermittent Bolus-not continuous infusion
  • 0.5-1.0 mg/kg maintain serum osmolarity lt 310-320
    mOsm/L
  • Renal failure
  • Volume depletion (make sure patient has a Foley)

29
HOB Elevation
  • Elevate head of bed-decrease ICP
  • Mechanical-helps drain blood by gravity
  • Keep neck in neutral position
  • Do not obstruct venous outflow
  • Do not allow blood to pool in cranium, which may
    occur if patient is left laying flat

30
Endotracheal Intubation
  • Intubation-not required, but airway protection
    and adequate ventilation are necessary
  • Rely on clinical suspicion, not GCS
  • Decreases ICP by decreasing CBF
  • pCO2 should be kept around 30-35
  • Avoid PCO2 less than 30
  • Decrease CBF to ischemia without further lowering
    ICP
  • Beneficial effect of sustained hyperventilation
    is not proven

31
Lidocaine
  • 1.5 mgs/kg
  • Depresses cough reflex
  • Blocks increases in ICP of intubated patients
    with space occupying lesions
  • Give 3 minutes before laryngoscopy

Lev, R, Rosen,Pp Prophylactic Lidocaine Use
Preintubation A review JOEM Vol 12 No 4 499-506
32
Paralytics/Sedation
  • Recommended
  • prevents increasing intrathoracic and venous
    pressures associated with coughing, suctioning,
    and bucking on ETT
  • Avoids ICP spikes-elevated ICP correlated to poor
    outcome

33
Barbituate Coma
  • Lowers ICP via lowering Cerebral metabolism
  • Use when other therapies fail
  • No evidence of improved outcome

34
BP Management
  • Lower blood pressure to decrease risk of ongoing
    bleeding from ruptured small arteries
  • Thus increasing hemorrhage volume
  • Overaggressive treatment of blood pressure may
    decrease cerebral perfusion pressure and worsen
    brain injury
  • Especially true with elevated ICP

35
SBP and ICH Incidence
Incidence Rate/100,000
Systolic Blood Pressure (mmHg)
36
BP Management
  • Maintain blood pressure below a mean arterial
    pressure of 130 mm Hg in persons with a history
    of hypertension
  • If there is an ICP monitor
  • ICP should be kept lt 20 m Hg
  • Cerebral perfusion pressure (MAP-ICP) should be
    kept gt 70 mm Hg

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
37
BP Management
  • Labetalol
  • Repetitive I.V. boluses of 20-80 mg q. 10 min or
    constant infusion of 0.5-2.0 mg/min
  • Nicardipine
  • 5-15 mg/hr I.V. infusion

Update on management of intracerebral hemorrhage
Neurosurg Focus 15 2003 1-6
38
Nipride
  • Nipride
  • 0.5-1.0 mics/kg/min
  • Theoretically can increase cerebral blood flow
    and thereby intracranial pressure

39
BP Management
  • Avoid hypotension
  • If systolic BP drops to less than 90 mmHg
  • fluid boluses-isotonic saline or colloids
  • Pressors
  • Phenylephrine, dopamine, Norepinephrine

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
40
Hypotension
  • Do not let Systolic BP fall below 90
  • Hypoxemia
  • Deleterious outcome 717 patients prospectively
    collected data set from Traumatic Coma Data bank
  • May be more important than hypertension

41
Cerebral Blood Flow
Neurology July, 2001 18-24
42
Cerebral Blood Flow
43
CBF Conclusions
  • In patients with small to medium sized acute ICH,
    autoregulation of CBF was preserved with arterial
    pressure reductions.
  • QureshiCritical Care Medicine. 27(5)965-971,
    May 1999-
  • 18 mongrel dogs
  • Reduction of MAP within normal autoregulatory
    limits of CPP had no adverse outcome on ICP or
    regional blood flow

44
BP Management
  • Treatment should be started within 6 hours of
    symptom onset
  • A Prospective Multicenter Study to Evaluate the
    Feasibility and Safety of Aggressive
    Antihypertensive Treatment in Patients with Acute
    Intracerebral Hemorrhage
  • Journal of Intensive Care Medicine, Vol 20, No 1
  • Burke, Dorfman-not yet published

45
Fever Management
  • Elevated temperatures can increase the degree of
    ischemic injury.
  • Etiologies include infection, neuronal injury,
    SIRS
  • Studies have demonstrated increased morbidity and
    mortality in patients with sustained temperature
    elevation.
  • Treat temperature gt 38.5 C
  • Acetaminophen or a cooling blanket best options.

46
Seizure Therapy
  • Neuronal injury may lead to seizures
  • Nonconvulsive seizures may contribute to coma in
    up to 10 of patients
  • Consider prophylactic antiepileptic therapy in
    setting of ICH
  • Lobar hemorrhage-35 seizure rate
  • Fosphenytoin or phenytoin

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
47
Seizure Therapy
  • No consensus exists on when to withdraw
    anticonvulsant therapy
  • If no seizure activity-withdraw at one month

Fewel Spontaneous Intracerebral Hemorrhage A
Review Neurosurg Focus 15 (4), 2003
48
Medical Therapy
  • Euvolemia
  • Isotonic crystalloid solutions
  • Electrolyte abnormalities
  • Correct deficits
  • Glucose management- gt140 start insulin

49
Medical Therapy
  • ABG
  • Correct hypoxemia, hypercapnia
  • Correct acid/base disorders
  • Coagulopathy
  • Correct INR
  • Correct Platelet counts

50
Steroids
  • Controversial
  • Three studies (159 patients)-no benefit
  • Tellez H, Bauer RB Dexamethasone as treatment in
    cerebrovascular disease. 1. A controlled study in
    intracerebral hemorrhage. Stroke 4541546, 1973
    (40)
  • Poungvarin N, Bhoopat W, Viriyavejakul A, et al
    Effects of dexamethasone in primary
    supratentorial intracerebral hemorrhage. N Engl J
    Med 31612291233, 1987 (93)
  • Desai P, Prasad K. Dexamethasone is not
    necessarily unsafe in Primary Supratentorial
    Cerebral Hemorrhage. J Neurol Neurosurg
    Psychiatry. 199865799-800 (26)
  • Neurosurgerical literature
  • Use when evidence of vasogenic edema and mass
    effect

Update on management of intracerebral hemorrhage
Neurosurg Focus 15 2003 1-6
51
Blood Clot
52
ICH Hemorrhage Volume
  • Old concept-Hemorrhage static process bleeding
    complete in a minutes
  • New concept-Hemorrhage is dynamic process
    continues for several hours

53
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54
ICH Growth Study Design
  • 103 patients
  • CT scan baseline 1 and 20 hours
  • Positive-increase hemorrhage 33
  • 38 patients with gt 33 growth in volume of
    parenchymal hemorrhage

55
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56
Hemorrhage Volume
  • Quick and dirty method
  • ABC/2
  • A-greatest hemorrhage diameter by CT
  • B-diameter 90 degrees to A
  • C-approximate number of CT slices with hemorrhage
    multiplied by slice thickness in cm

L Schwamm Guidelines for Emergency Department
Management of Brain Hemorrhage 2, 2004
57
Hematoma Volume Calculation
  • Formula for volume of an ellipsoid
  • 4/3? (A/2)(B/2)(C/2)
  • Simplified ABC/2

58
CT Scan
A (11cm)-greatest hemorrhage diameter B(4cm)-Diaem
ter at 90degrees C-2mm slices,8
slices 11x4x0.16/235.2 mls
B
A
59
Prognosis
  • Worse
  • Volume gt 60 cm3 and GCS lt 9
  • 91 dead at 30 days
  • Patients with volume over 30 cm3 only 1 / 71
    independent at 30 days
  • Intraventricular extension
  • Better
  • Volume lt 30 cm3 and GCS 9 or higher
  • 19 dead at 30 days

(Broderick, Stroke)
60
BP Hemorrhage Volume
Ohwaki, k Yano E Blood Pressure management in
Acute Intracerebral Hemorrhage Stroke
2004351364
61
BP Hemorrhage Volume
  • 76 patients
  • Hemetoma enlargement in 16 patients
  • Elevated BP increases the risk of hematoma
    enlargement

Ohwaki, k Yano E Blood Pressure management in
Acute Intracerebral Hemorrhage Stroke
2004351364
62
Rec Factor VIIa-Coumadin
63
ED Patient Management
  • Neurosurgery consulted
  • EVD placed in the ED
  • Patient taken to the OR for evacuation of
    hematoma
  • BP-119/79 P-92 RR-12

64
Patient Outcome
  • Next day brain flow studies
  • Patient declared brain dead
  • Patient extubated

65
ICH Surgical Outcome
Arch Neuro. 1990471103-1106
66
Surgical Outcome
Arch Neuro. 1990471103-1106
67
STICH Trial
Lancet 2005365387-97
68
STICH Trial-Methods
69
STICH Data
70
STICH Trial-Outcome
71
STICH Trial Outcome
72
STICH Conclusion
  • Patients with spontaneous supratentorial
    intracerebral hemorrhage in neurosurgical units
    show no overall benefit from early surgery when
    compared to initial conservative treatment

73
ICH Surgical Indications
  • Cerebellar hemorrhage gt 3 cm who are
    deteriorating or with brain stem compression and
    hydrocephalus from ventricular obstruction
  • Vascular malformation if lesion is surgically
    accessible and patient has chance for good
    outcome
  • Young patients with a moderate or large lobar
    hemorrhage who are clinically deteriorating

74
Non-Surgical ICH Pts
  • Small Hemorrhages (10 cm3)
  • Minimal neurological deficits
  • GCS lt 4 (excluding cerebellar hemorrhage with
    brain stem compression)

75
Poor Outcome Risk Factors
  • Large or increasing volume of hematoma
  • Low GCS on admission
  • Interventricular clot extension and/or
    hydrocehalus
  • Anticoagulation agents
  • Relative edema

Update on management of intracerebral hemorrhage
Neurosurg Focus 15 2003 1-6
76
What Can We Do?
  • Optimal medical management
  • Stop the bleeding
  • Factor VII
  • Call your Neurosurgeon
  • I have this patientyou do not need to come in

77
Stroke Centers
  • Hospitals should have systems in place to care
    for stroke patients
  • ED, Radiology, Neurology/Neurosurgery, Primary
    Care, Rehab
  • JACO lists Core Measures
  • ASA, Dysphagia, DVT prophylaxis, TPA considered,
    Lipid profile, smoking cessation, plan for rehab,
    stoke education
  • Similar to Cardiology

78
Key Learning Points
  • For management guidelines.
  • Broderick Guideline for the Management of
    Spontaneous Intracerebral Hemorrhage Stroke 4,
    1999, 905-915
  • Management and Prognosis of Severe Traumatic
    Brain Injury-a joint project of the Brain Trauma
    Foundation and the American Association of
    Neurosurgeons, 2000

79
Key Learning Points
  • CT scan is the most important tool in your
    diagnostic toolbox
  • Manage blood pressure, noting that guidelines are
    variable
  • Aggressively manage fever and seizures
  • Consider hyperventilation and paralytics in
    setting of increased ICP and deterioration

80
Key Learning Points
  • Most ICH patients are non-surgical
  • Consult your neurosurgeon early
  • Steroids-no benefit
  • There are promising new therapies such as Factor
    VII on the horizon

81
Questions?? www.ferne.orgferne_at_ferne.orgMarc
Dorfman, MDmdorfman_at_reshealthcare.org773 792
7921
ferne_acep_2005_spring_dorfman_ich_edrx
3/2/2005 94512 AM
Marc Dorfman, MD, FACEP, MACP
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