Title: Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005
1Optimizing the Management of Emergency
Department Intracerebral Hemorrhage
PatientsFERNE Satellite2005 ACEP Scientific
AssemblyWashington, DC 2005
2Intracerebral Hemorrhage
3 Marc Dorfman, MD, FACEP, MACPEM Residency
Program Director Resurrection Medical
CenterChicago, IL
Marc Dorfman, MD, FACEP, MACP
4Case Presentation
- 70 year old male
- Sudden onset, severe headache
- Took ASA for relief
- Collapsed
- Decreasing Mental Status
5Physical Exam
- T-98.6 P-61 BP-201/96 RR-16
- Pupils-equal, sluggish, reactive
- CV-NSR, no murmur
- Skin-Bruise and flank from fall
6More History
- Long standing Hypertension
- Unclear how well it was controlled
- Postive-Tobbaco/Alcohol
7Neurological Exam
- Neurological exam
- no gag reflex, withdraws to pain, 4 DTR
8GCS
9NIH Stroke Scale
NIH Stroke Scale
10NIHSS Score
11(No Transcript)
12Key Clinical Questions
- What is the epidemiology of ICH?
- What are the most common etiologies ICH?
- What is the pathophysiology of ICH?
- How does ICH present?
- Do patients with ICH present different than
Ischemic stroke patients? - Does hemorrhage volume and GCS predict outcome?
13Key Clinical Questions
- How does hemorrhage volume increase over time?
- What is the expected outcome of a patient with
ICH?
14Mission 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. - THIS IS CHANGING
Update on management of intracerebral hemorrhage
Neurosurgery Focus 15 2003 1-6
15Algorithm
Qureshi A, Tuhrim S Spontaneous Intracerebral
Hemorrhage NEJM, Vol 344, No 19 May 10, 2001
1450-1460
16Intracranial Hemorrhage
- Epidemiology
- Etiology
- Pathophysiology
17Stroke Epidemiology
Stroke
Hemorrhagic Stroke 15-20
Ischemic Stroke 80-85
Adapted from Scott PA, Barsan WG. Stroke,
transient ischemic attack, and other central
focal conditions.In Tintinalli J. Emergency
Medicine A Comprehensive Study Guide. 5th ed.
McGraw-Hill 20001430.
18ICH-Epidemiology
- 10-15 of all strokes (80 ischemic)
- More common in men than woman
- More common after 55 years of age
- Increased incidence in African Americans,
Japanese, and Hispanic populations
Priorities for Clinical Research in ICHNINDS ICH
Workshop Stroke March 2005
19ICH Epidemiology
- 30 day mortality 35-52
- 50 of these in first 48 hours
- 10 independent at 1 month
- One-fifth of survivors are independent at 6
months - 7000 operations annually in USA to remove blood
Broderick Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage Stroke
19930 905-915
20ICH Epidemiology-30 Day Mortality
- Men 48
- Woman 41
- African American 42
- Lobar 39
- Deep 45
- Pontine 44
- Cerebellar 64
Broderick Volume of ICH Stroke Vol 24, No 7
21Etiology
- Primary ICH (78-88 cases)-spontaneous rupture of
small vessels damaged by - Hypertension (basal ganglia, thalamus, pons,
cerebellum) - Cerebral Amyloid Angiopathy
22Etiology
- Pre-morbid Hypertension increases risk by 3.9
- Improved control of hypertension appears to
reduce the incidence if intracerebral hemorrhage
23Hypertensive ICH
- Hypertension
- Essential
- Eclampsia
- Sympathomimetics
- Cocaine
- Amphetamines
- Phenylpropanolamine
24Etiology
- Cerebral Amyloid Angiopathy-50 individuals
greater than 80 years old
25Etiology
- Low serum cholesterol (lt160 reason unknown)
- Alcohol consumption
- Previous ICH-especially lobar hemorrhage
26ICH Etiologies
- Trauma
- Vascular malformation
- Aneurysm
- Avm
- Cavernous hemangiomas
- Tumor
- Coagulopathy
- Vasculitis
27Pathophysiology
- Primary-immediate effects
- Hemorrhage growth
- Increased ICP
- Secondary effects
- Downstream effects
- Edema
- Ischemia
Priorities for Clinical Research in ICHNINDS ICH
Workshop Stroke March 2005
28ICH Hemorrhage Growth
- Several studies describe patients who had an
increase in the volume of parenchymal hemorrhage
on repeat CT scans
29ICH Hemorrhage Volume
- Old concept-Hemorrhage static process bleeding
complete in a minutes - New concept-Hemorrhage is dynamic process
continues for several hours
30ICH Volume Growth
31ICH 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
32ICH Volume Growth
Comparison of variables between Baseline and 1
hour CTs
33ICH Growth Study Conclusion
- Substantial early hemorrhage growth in patients
with with intracerebral hemorrhage is common and
is associated with neurological deterioration. - Randomized treatment trials are needed to
determine whether this ongoing bleeding and
frequent neurological deterioration can be
improved
34ICH Hemorrhage Growth
- Hematoma growth occurs in patients with normal
coagulation profiles - Hematoma enlargement is associated with a worse
outcome - Hematoma growth occurs within the first few hours
(up to 40 in the first 3 hours) and is rare
after 24 hours
Priorities for Clinical Research in ICHNINDS ICH
Workshop Stroke March 2005
35Hemorrhage Growth-Predictors
- Initial Hematoma volume
- Early Presentation
- Irregular shape
- Liver disease
- Hypertension
- Hyperglycemia
- Alcohol use
- Hypofibrinogenima
Priorities for Clinical Research in ICHNINDS ICH
Workshop Stroke March 2005
36Hemorrhage Volume-Mortality
- Volume graters 60 cm3
- Deep-93
- Lobar-71
- Volumes 30-60 cm 3
- Deep-60
- Lobar-60
- Cerebellar-75
- Volumes less 30 cm
- Deep-23
- Lobar-7
- Cerebellar-57
Broderick Volume of ICH Stroke Vol 24, No 7
37Hemorrhage 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 slick thickness in cm
L Schwamm Guidelines for Emergency Department
Management of Brain Hemorrhage 2, 2004
38Secondary Effects of ICH
- Hematoma initiates edema
- Edema is from osmotically active proteins from
the clot - Vasogenic and cytotoxic edema lead to disruption
of blood brain barrier and death to neurons - There may be unidentified secondary mediators of
both neuronal injury and edema ( nuclear factor
kappa-beta)
Qureshi A, Tuhrim S Spontaneous Intracerebral
Hemorrhage NEJM, Vol 344, No 19 May 10, 2001
1450-1460
39ICH-Presentation
- Basal ganglia (50)
- Contralateral hemiparesis, sensory loss,
conjugate gaze - Lobar regions (20-50)
- Contralateral hemiparesis or sensory loss,
aphasia, neglect, or confusion - Thalamus (10-15)
- Contralateral hemiparesis, sensory loss, gaze
paresis - Pons (5-12)
- Quadriparesis, facial weakness, decreased level
consciousness - Cerebellum (1-5)
- Ataxia, miosis, vertigo, gaze paresis
Acute Evaluation and Management of Intracerebral
Hemorrhage Stroke 1996
40ICH Presentation
- Hypertension (90)
- Altered mental status (50)
- Headache (40)
- Vomiting (49)
- Seizures (6-7)
41ICH-Hypertension
- Risk factor for bleeding
- May promote rebleeding (logical but unproven)
- The big question-Will treating hypertension
promote ischemia or how low can we go?
42Altered Mental Status
- Early decrease in level of consciousness seen
about 50 patients - Uncommon finding in patients with ischemic stroke
Broderick Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage Stroke
199930 905-915
43Headache
- Occurs about 40 of patients
- 17 with ischemic stroke
Broderick Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage Stroke
199930 905-915
44Vomiting
- 49 ICH
- 2 Ischemic stroke
- 45 with SAH
Broderick Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage Stroke
199930 905-915
45ICH CVA
Decrease LOC 50 Uncommon
Headache 40 17
Vomiting 49 2
46Seizure
- 28 of patients first 72 hours
- Mostly lobar
- Associated with Neurological worsening
- Trend toward worse outcome
Priorities for Clinical Research in ICHNINDS ICH
Workshop Stroke March 2005
47Presentation
- Sudden onset of focal neurological deficit
- Progresses over minutes to hours
- Headache, N/V, Decreased LOC, Elevated BP
Broderick Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage Stroke
199930 905-915
48ICH Diagnosis
CT scan is the most effective tool in the ED
CT scan is excellent for imaging blood
49Poor 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
Neurosurgery Focus 15 2003 1-6
50Poor Outcomes- Intraventricular Extension
Hydrocephalus
- Independent prognostic indicator
- Important cause of neurological deterioration
- Location importance?
- Ventriculostomy-helpful?
Priorities for Clinical Research in ICHNINDS ICH
Workshop Stroke March 2005
51Outcome predictor
- Initial GCS
- Initial hematoma volume
- If GCS lt 9 and hematoma volume gt 60 ml mortality
at one month 90 - GCS gt 9 and hematoma volume lt 30 ml mortality gt
17
Broderick, Brott Volume if intracerebral
hemorrhage a powerful and easy-to-use predictor
of 30 day mortality. Stroke 199324987-93
52ICH Score
- UCSF
- GCS (3-4(2) 5-12(1) 13-15(0)
- ICH volume gt30(1) lt30(0)
- IVH (yes, no)
- Infratentorial origin of ICH (yes,no)
- Age lt80 yrs(0) or gt80 yrs(1)
Hemphill III, Bonovich The ICH
ScoreStroke,April 2001 891-896
53ICH Score
- If score was six or greater all patients died
- If score was zero all patients lived
Hemphill III, Bonovich The ICH
ScoreStroke,April 2001 891-896
54ED Patient Management
- Patient intubated in the ED
- Stared on Nicardapine
- BP-160/84 P-92 RR-Vented
- Eyes-Pupils fixed
- Patient expired within two hours of arrival
55Key Learning Points
- ICH makes up only 10-15 strokes
- ICH occurs in hypertensives greater then 55 yrs
of age - ICH presents differently than ischemic stroke
- ICH volume expands over time-this is a marker for
poor outcome - One can risk stratify poor outcomes based on
simple numbers such as GCS, hemorrhage volume
56Questions?? www.ferne.orgferne_at_ferne.orgMarc
Dorfman, MDmdorfman_at_reshealthcare.org773 792
7921
ferne_acep_2005_ich_dorfman_path_notes_100206
Marc Dorfman, MD, FACEP, MACP