Guidelines for the management of spontaneous ICH

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Guidelines for the management of spontaneous ICH
AHA, 1999

• ??? ???
• 91-04-13

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Introduction

• ICH 2 times SAH
• NO conclusively report
• Risk Factors
• Age
• HTN pathophysiological change in small artery
  and arterioles
• Amyloid angiopathy
• AVM.

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Introduction

• 1997 in USA 37,000 ICH
• 35-52 dead within 1 month(half of the death die
  within first 2 days.)
• Only 10 live independently in 1 month
• 20 in 6th months.

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Emergent diagnosis of ICH and causes

• Focal neurological deficit
• Headache, nausea, vomiting
• Decrease consciousness(50)
• Vomiting ICH, In cerebral hemisphere stroke
  posterior fossa
• Elevated BP in 90 cases
• Seizure 6-7, more common in lobar than deep ICH
• CAREFUL HISTROY is important

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Emergent diagnosis of ICH and causes

• Brain CT
• Initial diagnostic
• D/D ischemic and ICH
• Contrast if highly suspect vascular abnormality
• Lobar hemorrhage are likely amyloid angiopathy

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TABLE1
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Diagnosis of ICH - summary and recommendation

• Early neurological deterioration or death,
  vomiting, hypertension
• CT of head as initial procedure(level I, Grade A)
• Angiography for all patient without known
  causes(Level V, grade C)
• Not candidate in older hypertensive patients in
  whom structure lesion not suspected by brain CT
  (level V, grade C)
• MRI, MRA if consider carvenous malformation in
  normatensive with lobar hemorrhage and normal
  angiographic who are surgical candidates(level V,
  Grade C)

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Treatment of acute ICH

• Initial management in ED ABC, and neurological
  deficits. External trauma, pressure sore,
  compartment syndrome.
• ETT lt 2week, tracheostomy in gt2wks
• Medical treatment 4 studies None showed
  significant benefit
• steroid versus placebo
• hemodilution versus best medical therapy
• Glycerol versus placebo.
• BP proven no relation between baseline BP and
  subsequent ICH, conversely, overtreatment of BP
  will decrease brain blood flow

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BP and ICH

• Maintain MAP below 130 mm-Hg
• Cerebral blood pressure(MAP-ICP)gt70 mmHg
• MAPgt110 mmHg should be avoided in post operative
  period.

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BP and ICH
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Management of IICP

• Osmotherapy, controlled hyperventilation,
  barbiturate coma.
• IICP ICP gt20mmHg. gt5 mins
• Treatment goal lt20mmHg, CPPgt70mmHg.
• Patient with suspected elevated ICP and poor
  conscious (GCS lt9)are candidate for invasive ICP
  monitoring

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Management of IICP

• Drainage according to clinical and ICP level, lt7
  days(level V, grade C)
• Use anti-infection(level V, grade C)
• Hyperventilation PaCO2 keep 30-35mmHg
• Fluid management CVP keep 5-12 mmHg, Pulmonary
  wedge pressure10-14 mmHg

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Management of IICP

• Output urine500cc insensible loss plus 300cc
  per degree
• Prevention of seizure favored phenytoin keep
  14-23 ug/ml.(level V, grade C)
• BT use scanol and cooling blankets if BT gt38.5 C
  
• WATCH out for pul.embolism for bed ridden patient.

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Surgical intervention

• Remove blood clot as quickly as possible
• Amount ???/2
• gt25-30cc, midline shiftgt1cm

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TABLE 5
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Guideline for Surgical Removal of ICH - summary

• 1. lt10 cm no nerological deficit-medical(level
  II-V, grade B)
• 2. GCS lt4, medically(level II-V, grade B)
• 3. Cerebral hemorrhagegt3cm and neuro
  deterioration and brain stem compression,
  hydrocephalus(level III-V, grade C)
• 4. Young patientgt50cc with deterioration under
  observation-surgical(level II-V, grade B)
• 5. Structural lesion aneurysm or vascular
  malformation surgical(level III-V, grade C)

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Prevention of ICH

• BP control reduce risk in middle aged and old by
  36-48
• SHEP even treat SBP reduce 50
• Other risk factor
• fruits and vegetable(ischemic and ICH)
• Quit smoking(stroke and SAH,no ICH)
• Quit alcohol consumption(not proven)
• INRgt3. Care selection in MI and stroke cases

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Prevention ICH - summary

• Treatment HTN(level I-II, grade A)
• Careful control anticoagulant prescribed with
  warfarin(level I, grade A)
• Careful selection in MI and stroke patient for
  thrombolytic (level I, grade A)
• Increase fruits and vegetable, stop heavy alcohol
  and sympathomimetic agent(level III-V, grade C)