Intracerebral Hemorrhage Andrew Asimos, MD Associate Director Stroke Care Program Carolinas Medical - PowerPoint PPT Presentation

1 / 59
About This Presentation
Title:

Intracerebral Hemorrhage Andrew Asimos, MD Associate Director Stroke Care Program Carolinas Medical

Description:

Intracerebral Hemorrhage Andrew Asimos, MD Associate Director Stroke Care Program Carolinas Medical – PowerPoint PPT presentation

Number of Views:820
Avg rating:3.0/5.0
Slides: 60
Provided by: uic9
Category:

less

Transcript and Presenter's Notes

Title: Intracerebral Hemorrhage Andrew Asimos, MD Associate Director Stroke Care Program Carolinas Medical


1
Intracerebral Hemorrhage Andrew Asimos,
MDAssociate DirectorStroke Care
ProgramCarolinas Medical CenterCharlotte,
NCClinical Assistant Professor of Emergency
MedicineUniversity of North CarolinaChapel
Hill, NC
2
Case Presentation
  • ED setting
  • Community ED
  • On-call neurologist
  • Neurosurgical services not available
  • CT scanner (not located in or adjacent to the ED)
  • No MRI
  • ICU beds available, on-call intensivist

3
Case Presentation
  • 39 yo black male transported via paramedics with
    complaint of headache and right sided facial
    droop paralysis starting 20 minutes PTA
  • Reported SBP of ?220 mm Hg in the field
  • 16 g IV left anticubital fossa at KVO
  • Not following commands
  • Code Stroke protocol initiated

4
Initial ED Evaluation
  • Obese black male
  • Drowsy, but arousable with verbal stimuli
  • Dysarthric with unintelligible speech, adequately
    handling secretions
  • No respiratory difficulty or abnormal breathing
    pattern
  • Diaphoretic with normal heart sounds, bounding
    pulses

5
Initial Vital Signs
  • BP
  • 220/125 mm Hg right arm
  • 212/116 mm Hg left arm
  • Pulse
  • 64 regular
  • Temperature
  • 99.9 F rectally
  • Respiratory rate
  • 18 regular

6
Past Medical History via family
  • Hypertension, depression, seasonal allergies
  • NKDA
  • Smokes tobacco, consumes 1-2 alcoholic
    beverages/day
  • Medications
  • Nifedipine XL
  • Fexofenadine
  • Nefazodone

7
First / Next ED Management Priority?
  • More extensive history or physical exam?
  • More extensive neurological exam?
  • Blood Pressure treatment?
  • Head CT?
  • Aggressive airway management?

8
Neurologic Exam
  • NIHSS Score 23
  • Obtunded LOC
  • Unable to perform simple commands on left
  • Partial gaze palsy to the left
  • Complete right sided facial paralysis
  • No movement of right arm or leg
  • Severe sensory loss on the right
  • Global aphasia
  • Unintelligible speech
  • Profound neglect of right hemispace

9
Initial Head CT
10
Major ED ICH Management Issues
  • Scientific evidence for recommended treatment
  • Ability to diagnose based on clinical
    presentation
  • BP management guidelines
  • ICP treatment recommendations
  • Who needs a neurosurgeon

11
Spontaneous Intracerebral Hemorrhage (ICH)
  • ICH over twice as common as SAH
  • 8 - 13 of all strokes
  • Greater chance of death or major disability than
    with ischemic stroke or SAH
  • More common in males, blacks, and the elderly
  • 50 cases due to the effects of chronic
    hypertension on intracranial perforating arteries

Broderick J et al. J Neurosurg. 199378188-191.
12
Evidence Based Treatment for ICH
  • Lack of RCT on ICH
  • As of 1995
  • 4 small randomized surgical trials (353 total
    pts)
  • 4 small medical trials (513 total pts)
  • Broad variability in treatment
  • No proven benefit of surgical or medical
    treatment for ICH based on RCT
  • 7000 operations/year in US to remove ICH

Broderick JP et al. Stroke. 199930905-915
13
Evidence Based Treatment for ICH
14
Classic Presentation of ICH
  • Sudden onset of a focal deficit progressing over
    minutes to hours
  • Headache (?40)
  • Nausea Vomiting
  • Early decreased LOC (?50)
  • Elevated blood pressure (?90)
  • Early symptom progression

Gorelick PB et al. Neurology.
1986361445-1450. Caplan L. General symptoms
and signs. In Kase CS, Caplan LR, eds.
Intracerebral hemorrhage. Stroke. 1997281-5.
15
Significance of Vomiting
  • Incidence of vomiting in the Harvard Stroke
    Registry
  • Supratentorial ICH 49
  • Carotid territory ischemia 2
  • SAH 45
  • Vomiting common in any type of posterior fossa
    stroke

Caplan L. General symptoms and signs. In Kase
CS, Caplan LR, eds. Intracerebral hemorrhage.
Stroke. 1997281-5.
16
Presentation of ICH
  • Uncommon on awakening from sleep
  • Seizures occur in only ?6 of ICH pts
  • More common with lobar versus deep hemorrhages

Caplan L. General symptoms and signs. In Kase
CS, Caplan LR, eds. Intracerebral hemorrhage.
Stroke. 1997281-5.
17
Significance of Symptom Progression
  • Early progression of neurologic deficit may
    suggest ICH versus ischemic stroke or SAH

of Stroke Subtypes with Gradual Progression of
Symptoms
Harvard Stroke Registry Michael Reese Stroke
Registry
Caplan L. General symptoms and signs. In Kase
CS, Caplan LR, eds. Intracerebral hemorrhage.
Stroke. 1997281-5.
18
Distinguishing ICH from Ischemic Stroke
  • No collection of clinical features sufficiently
    predictive

19
Distinguishing ICH from Ischemic Stroke
  • No collection of clinical features sufficiently
    predictive

20
Distinguishing ICH from Ischemic Stroke
  • No collection of clinical features sufficiently
    predictive

21
Epidemiology of ICH
  • Advancing age and HTN most important risk factors
  • Slight gender predisposition to men
  • Significantly more common in young and middle
    aged blacks
  • Higher reported incidence among Asian populations

Broderick JP et al. Stroke. 199930905-915
22
Causes of ICH
  • Vascular malformations
  • Ruptured aneurysms
  • Coagulation disorders
  • Use of anticoagulants or thrombolytics
  • Hemorrhage into a cerebral infarct
  • Bleeding into brain tumors
  • Drug abuse

Broderick J. Intracerebral hemorrhage. In
Gorelick PB, Alter M, eds. Handbook of
Neuroepidemiology. New York, NY Marcel Dekker,
Inc 1994141-167.
23
ICH Location May Suggest Cause
  • Hypertensive small vessel disease
  • Putamen
  • Global Pallidum
  • Thalamus
  • Internal capsule
  • Deep periventricular white matter
  • Pons
  • Cerebellum
  • Amyloid angiopathy in the elderly
  • Lobar hemorrhage

24
Outcome from ICH
  • Of the estimated 37,000 Americans who experienced
    an ICH in 1997
  • 35-50 dead at one month
  • Half of all deaths within the first 2 days
  • Only 10 living independently at one month
  • 20 independent at 6 months
  • Volume of intraventricular hemorrhage is an
    important determinant of outcome in
    supratentorial ICH

Broderick J et al. J Neurosurg.
199378188-191. Anderson et al. J Neurol
Neurosurg Psychiatry. 199457936-940. Counsell C
et al. Cerebrovasc Dis. 1995526-34. Tuhrim S et
al. Critical Care Medicine. 199927(3)617-21.
25
Initial Diagnostic Evaluation
  • Non-contrast head CT is key
  • Readily identifies blood
  • Size and location of hemorrhage
  • May expose contributing structural abnormalities
  • Tumor
  • AVM
  • Reveals structural complications
  • Herniation
  • Intraventricular hemorrhage
  • Hydrocephalus

26
MM ICH Volume and GCS
  • Mortality
  • gt 60 cc blood GCS ? 8
  • 30 day mortality over 90
  • gt 90 cc blood
  • Mortality almost 100
  • ? 30 cc blood GCS ? 9
  • 30 day mortality 19
  • Morbidity
  • gt 30 cc blood
  • 1 / 71 independent at 30 days

27
Initial Diagnostic Evaluation
  • CBC
  • PT/PTT
  • Electrolytes
  • Electrocardiography
  • Chest radiography

Broderick JP et al. Stroke. 199930905-915
28
Returning to Our Case
  • Upon return from CT
  • BP remains ? 220/125 mm Hg
  • Increasingly obtunded
  • Drooling
  • Pulse ox 91 on 2 liters O2 nasal cannula
  • Deficits essentially unchanged

29
Initial ED Management of ICH
  • ABCs
  • Detection of focal neurologic deficits
  • Detection of signs of external trauma

30
Airway and Oxygenation
  • Airway protection and adequate ventilation
    critical
  • Aggressive airway management if decreasing LOC or
    signs of brainstem dysfunction
  • RSI with drugs to avoid reflex arrhythmias and/or
    hemodynamic derangement

31
Aggressive Airway Management Critical
Prophylactic intubation may prevent the necessity
of intubating in CT
performed in
Bad Idea
32
Returning to Our Case
  • Patient successfully RSId
  • Lidocaine
  • Etomidate
  • Succinylcholine

33
Medical Management of ICH Randomized Trials
  • Four small trials
  • Steroid versus placebo (2 trials)
  • Hemodilution versus best medical therapy
  • Glycerol versus placebo
  • No demonstrated benefit
  • Infectious complications worse with steroid
    treatment

Italian Acute Stroke Study Group. Lancet.
19881318-321. Yu YL et al. Stroke.
199223967-971. Poungvarian N et al. N Eng J
Med. 19873161229-1233. Tellez H, Bauer R.
Stroke. 19724 541-546.
34
Blood Pressure Management in ICH
  • Optimal BP level should be somewhat
    individualized
  • Treatment recommendations for elevated BP in ICH
    more aggressive than for ischemic stroke

Broderick JP et al. Stroke. 199930905-915 Adams
HP Jr et al. Circulation. 19969411671174.
35
Blood Pressure Management in ICH
  • Theoretical rationale for lowering BP is to
    decrease risk of ongoing bleeding from ruptured
    small arteries and arterioles

Brott T et al. Stroke. 19972815.
36
Blood Pressure Management in ICH
  • Theoretical rationale for lowering BP is to
    decrease risk of ongoing bleeding from ruptured
    small arteries and arterioles

Brott T et al. Stroke. 19972815.
37
Blood Pressure Management in ICH
  • Overaggressive BP treatment may decrease CPP and
    theoretically worsen brain injury, particularly
    in the setting of increased intracranial pressure

CPP MAP - ICP
38
Blood Pressure Management in ICH
Adapted from Brott T, Reed RL. Stroke.
198920694697.
39
Blood Pressure Management in ICH
Broderick JP et al. Stroke. 199930905-915
40
Returning to Our Case
  • Blood pressure lowered to 170/100 mm Hg after 3
    doses of labetalol
  • 600 ccs of 0.9 NS intravenously infused thus far
  • No witnessed seizure activity
  • Repeat rectal temperature 100.6 F

41
Fluid Management
  • Goal is euvolemia
  • Avoid dextrose containing
  • solutions

Broderick JP et al. Stroke. 199930905-915
42
Seizure Prophylaxis
  • Prophylactic antiepileptic therapy may be
    considered
  • Phenytoin is agent of choice
  • Generally reserved for lobar hematomas
  • Data supporting this therapy are lacking

Broderick JP et al. Stroke. 199930905-915
43
Management of Body Temperature
  • Maintain at normal levels
  • Acetaminophen 650 mg
  • Cooling blankets

44
Returning to Our Case
  • IVF rate reduced to KVO
  • 650 mg tylenol suppository administered
  • Blood pressure begins rising again
  • Pulse decreases to 50s

45
Management Options for Increased ICP After ICH
  • Osmotherapy
  • Controlled hyperventilation
  • Barbituate coma
  • Ventricular drains

Broderick JP et al. Stroke. 199930905-915
46
Causes of Increased ICP After ICH
  • Mass effect of the hematoma
  • Secondary Hydrocephalus
  • Edema

47
Stepwise Recommended Treatment to Control ICP
  • Osmotherapy
  • Mannitol 20 (0.25-0.5 g/kg every 4 hrs)
  • In the ED, reserved for pts with clinical
    deterioration associated with mass effect
  • Furosemide (10 mg every 2-8 hrs) may be added to
    maintain an osmotic gradient

Broderick JP et al. Stroke. 199930905-915
48
Stepwise Recommended Treatment to Control ICP
  • Hyperventilation
  • Hypocarbia causes cerebral vasoconstriction
  • Reduction in CBF almost immediate
  • Peak ICP reduction about 30 minutes after pCO2
    change
  • Reduction of pCO2 to 35-30 mmHg
  • Best achieved by raising ventilation rate at
    constant tidal volume (12-14 mL/kg)
  • Lowers ICP 25-30 in most pts

Broderick JP et al. Stroke. 199930905-915
49
Stepwise Recommended Treatment to Control ICP
  • Neuromuscular paralysis
  • In combination with adequate sedation reduces
    elevated ICP by preventing increases in
    intrathoracic and venous pressure
  • Nondepolarizing agents preferred

Broderick JP et al. Stroke. 199930905-915
50
Returning to Our Case
  • Patient bolused with 50 gm mannitol
  • ABG after 20 minutes on the ventilator reveals
    pCO2 to 32 mmHg
  • Patient bolused with 8 mg midazolam and 10 mg
    vecuronium
  • Charge nurse in the ICU wants to know if youll
    need a bed or will be transferring the patient

51
Recommendations for Surgical Treatment for ICH
  • Nonsurgical Candidates
  • Small hemorrhages
  • Minimal neurologic deficits
  • GCS score ? 4
  • If cerebellar hemorrhage with brainstem
    compression, may be a candidate for lifesaving
    surgery

52
Recommendations for Surgical Treatment for ICH
  • Surgical Candidates
  • Cerebellar hemorrhage gt3 cm with neurological
    deterioration or brainstem compression and
    hydrocephalus from ventricular obstruction
  • Associated structural lesion with chance for good
    outcome and surgical accessibility
  • Young with moderate to large hemorrhage and
    clinical deterioration

53
Returning to Our Case
  • Patient transferred to tertiary care center with
    neurosurgical expertise

ED Presentation
54
Returning to Our Case
  • Undergoes craniotomy and evacuation of hemorrhage
    with ventriculostomy placement

ED Presentation
24 hrs after ED Presentation
55
Returning to Our Case
  • Followup CT shows excellent resolution of
    hemorrhage

ED Presentation
24 hrs after ED Presentation
5 days after ED Presentation
56
Patient Status at Discharge
  • Discharged to extended care facility 24 days
    after admission
  • Intermittently following commands with left arm,
    right sided hemiparesis, apraxia, and aphasia
  • Antihypertensive regimen
  • Clonidine
  • Minoxidil
  • Atenolol

57
Value of Neurosurgical Intervention?
  • A meta-analysis suggests that for patients with
    intraventricular extension of ICH, treatment with
    ventricular drainage combined with fibrinolytics
    may improve outcome
  • Data support a RCT of surgical evacuation versus
    conservative treatment
  • Patients lt 60-65 years of age
  • Admission GCS of 6-11
  • Hematoma not mainly located in the thalamus
  • Volume in the range of 30-100 ml
  • Midline shift lt 10 mm

Nieuwkamp DJ et al. J Neurology.
2000247(2)117-21. Hardemark HG et al.
Cerebrovascular Diseases. 9(1)10-21, 1999
Jan-Feb.
58
Future Trends for ICH
  • Large prospective, randomized, placebo controlled
    trials to examine
  • Judicious application of current therapeutic
    modalities
  • Ventricular drainage combined with fibrinolytics
  • Stereotactic CT-guided aspiration and
    thrombolysis of intracerebral hematoma
  • Potential benefit of proposed new treatment
    modalities
  • Neuroprotectives

Nieuwkamp DJ et al. J Neurology.
2000247(2)117-21. Hardemark HG et al.
Cerebrovascular Diseases. 9(1)10-21, 1999
Jan-Feb.
59
ICH Summary
  • Recognize that scientific evidence for
    recommended treatment is lacking
  • History and exam are unreliable in distinguishing
    ICH from ischemic stroke
  • BP management guidelines are not based on RCT
  • ICP treatment should be stepwise
  • Not all patients need a neurosurgeon
Write a Comment
User Comments (0)
About PowerShow.com