Title: Intracerebral Hemorrhage Andrew Asimos, MD Associate Director Stroke Care Program Carolinas Medical
1Intracerebral Hemorrhage Andrew Asimos,
MDAssociate DirectorStroke Care
ProgramCarolinas Medical CenterCharlotte,
NCClinical Assistant Professor of Emergency
MedicineUniversity of North CarolinaChapel
Hill, NC
2Case 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
3Case 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
4Initial 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
5Initial 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
6Past Medical History via family
- Hypertension, depression, seasonal allergies
- NKDA
- Smokes tobacco, consumes 1-2 alcoholic
beverages/day - Medications
- Nifedipine XL
- Fexofenadine
- Nefazodone
7First / Next ED Management Priority?
- More extensive history or physical exam?
- More extensive neurological exam?
- Blood Pressure treatment?
- Head CT?
- Aggressive airway management?
8Neurologic 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
9Initial Head CT
10Major 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
11Spontaneous 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.
12Evidence 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
13Evidence Based Treatment for ICH
14Classic 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.
15Significance 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.
16Presentation 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.
17Significance 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.
18Distinguishing ICH from Ischemic Stroke
- No collection of clinical features sufficiently
predictive
19Distinguishing ICH from Ischemic Stroke
- No collection of clinical features sufficiently
predictive
20Distinguishing ICH from Ischemic Stroke
- No collection of clinical features sufficiently
predictive
21Epidemiology 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
22Causes 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.
23ICH 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
24Outcome 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.
25Initial 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
26MM 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
27Initial Diagnostic Evaluation
- CBC
- PT/PTT
- Electrolytes
- Electrocardiography
- Chest radiography
Broderick JP et al. Stroke. 199930905-915
28Returning 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
29Initial ED Management of ICH
- ABCs
- Detection of focal neurologic deficits
- Detection of signs of external trauma
30Airway 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
31Aggressive Airway Management Critical
Prophylactic intubation may prevent the necessity
of intubating in CT
performed in
Bad Idea
32Returning to Our Case
- Patient successfully RSId
- Lidocaine
- Etomidate
- Succinylcholine
33Medical 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.
34Blood 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.
35Blood 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.
36Blood 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.
37Blood 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
38Blood Pressure Management in ICH
Adapted from Brott T, Reed RL. Stroke.
198920694697.
39Blood Pressure Management in ICH
Broderick JP et al. Stroke. 199930905-915
40Returning 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
41Fluid Management
- Goal is euvolemia
- Avoid dextrose containing
- solutions
Broderick JP et al. Stroke. 199930905-915
42Seizure 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
43Management of Body Temperature
- Maintain at normal levels
- Acetaminophen 650 mg
- Cooling blankets
44Returning to Our Case
- IVF rate reduced to KVO
- 650 mg tylenol suppository administered
- Blood pressure begins rising again
- Pulse decreases to 50s
45Management Options for Increased ICP After ICH
- Osmotherapy
- Controlled hyperventilation
- Barbituate coma
- Ventricular drains
Broderick JP et al. Stroke. 199930905-915
46Causes of Increased ICP After ICH
- Mass effect of the hematoma
- Secondary Hydrocephalus
- Edema
47Stepwise 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
48Stepwise 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
49Stepwise 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
50Returning 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
51Recommendations 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
52Recommendations 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
53Returning to Our Case
- Patient transferred to tertiary care center with
neurosurgical expertise
ED Presentation
54Returning to Our Case
- Undergoes craniotomy and evacuation of hemorrhage
with ventriculostomy placement
ED Presentation
24 hrs after ED Presentation
55Returning to Our Case
- Followup CT shows excellent resolution of
hemorrhage
ED Presentation
24 hrs after ED Presentation
5 days after ED Presentation
56Patient 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
57Value 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.
58Future 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.
59ICH 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