Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005 - PowerPoint PPT Presentation

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Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005

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Title: Intracranial Hemorrhage Author: Marc Dorfman, MD, FACEP, MACP Last modified by: FERNE Created Date: 5/26/2000 6:35:20 PM Document presentation format – PowerPoint PPT presentation

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Title: Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005


1
Optimizing the Management of Emergency
Department Intracerebral Hemorrhage
PatientsFERNE Satellite2005 ACEP Scientific
AssemblyWashington, DC 2005
2
Intracerebral Hemorrhage
3
Marc Dorfman, MD, FACEP, MACPEM Residency
Program Director Resurrection Medical
CenterChicago, IL
Marc Dorfman, MD, FACEP, MACP
4
Case Presentation
  • 70 year old male
  • Sudden onset, severe headache
  • Took ASA for relief
  • Collapsed
  • Decreasing Mental Status

5
Physical 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

6
More History
  • Long standing Hypertension
  • Unclear how well it was controlled
  • Postive-Tobbaco/Alcohol

7
Neurological Exam
  • Neurological exam
  • no gag reflex, withdraws to pain, 4 DTR

8
GCS
  • Eyes-0
  • Verbal-0
  • Motor-4

9
NIH Stroke Scale
NIH Stroke Scale
10
NIHSS Score
  • Stroke scale 38

11
(No Transcript)
12
Key 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?

13
Key Clinical Questions
  • How does hemorrhage volume increase over time?
  • What is the expected outcome of a patient with
    ICH?

14
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.
  • THIS IS CHANGING

Update on management of intracerebral hemorrhage
Neurosurgery Focus 15 2003 1-6
15
Algorithm
Qureshi A, Tuhrim S Spontaneous Intracerebral
Hemorrhage NEJM, Vol 344, No 19 May 10, 2001
1450-1460
16
Intracranial Hemorrhage
  • Epidemiology
  • Etiology
  • Pathophysiology

17
Stroke 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.
18
ICH-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
19
ICH 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
20
ICH 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
21
Etiology
  • Primary ICH (78-88 cases)-spontaneous rupture of
    small vessels damaged by
  • Hypertension (basal ganglia, thalamus, pons,
    cerebellum)
  • Cerebral Amyloid Angiopathy

22
Etiology
  • Pre-morbid Hypertension increases risk by 3.9
  • Improved control of hypertension appears to
    reduce the incidence if intracerebral hemorrhage

23
Hypertensive ICH
  • Hypertension
  • Essential
  • Eclampsia
  • Sympathomimetics
  • Cocaine
  • Amphetamines
  • Phenylpropanolamine

24
Etiology
  • Cerebral Amyloid Angiopathy-50 individuals
    greater than 80 years old

25
Etiology
  • Low serum cholesterol (lt160 reason unknown)
  • Alcohol consumption
  • Previous ICH-especially lobar hemorrhage

26
ICH Etiologies
  • Trauma
  • Vascular malformation
  • Aneurysm
  • Avm
  • Cavernous hemangiomas
  • Tumor
  • Coagulopathy
  • Vasculitis

27
Pathophysiology
  • Primary-immediate effects
  • Hemorrhage growth
  • Increased ICP
  • Secondary effects
  • Downstream effects
  • Edema
  • Ischemia

Priorities for Clinical Research in ICHNINDS ICH
Workshop Stroke March 2005
28
ICH Hemorrhage Growth
  • Several studies describe patients who had an
    increase in the volume of parenchymal hemorrhage
    on repeat CT scans

29
ICH Hemorrhage Volume
  • Old concept-Hemorrhage static process bleeding
    complete in a minutes
  • New concept-Hemorrhage is dynamic process
    continues for several hours

30
ICH Volume Growth
31
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

32
ICH Volume Growth
Comparison of variables between Baseline and 1
hour CTs
33
ICH 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

34
ICH 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
35
Hemorrhage 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
36
Hemorrhage 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
37
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 slick thickness in cm

L Schwamm Guidelines for Emergency Department
Management of Brain Hemorrhage 2, 2004
38
Secondary 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
39
ICH-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
40
ICH Presentation
  • Hypertension (90)
  • Altered mental status (50)
  • Headache (40)
  • Vomiting (49)
  • Seizures (6-7)

41
ICH-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?

42
Altered 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
43
Headache
  • Occurs about 40 of patients
  • 17 with ischemic stroke

Broderick Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage Stroke
199930 905-915
44
Vomiting
  • 49 ICH
  • 2 Ischemic stroke
  • 45 with SAH

Broderick Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage Stroke
199930 905-915
45
ICH CVA
Decrease LOC 50 Uncommon
Headache 40 17
Vomiting 49 2
46
Seizure
  • 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
47
Presentation
  • 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
48
ICH Diagnosis
CT scan is the most effective tool in the ED
  • CT scan

CT scan is excellent for imaging blood
49
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
Neurosurgery Focus 15 2003 1-6
50
Poor 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
51
Outcome 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
52
ICH 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
53
ICH 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
54
ED 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

55
Key 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

56
Questions?? 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
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