Intracerebral Hemorrhage

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Intracerebral Hemorrhage
2
Marc Dorfman, MD, FACEP, MACPEM Residency
Program Director Resurrection Medical
CenterChicago, IL
Marc Dorfman, MD, FACEP, MACP
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Case Presentation

• 57 year old female
• Sudden onset, severe headache
• Took ASA for relief
• Slurred speech
• Collapsed

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Physical Exam

• T 99.4 P52 BP 195/99 RR13
• Pupils-2 mm reactive
• Neck-no JVD, bruits
• CV-bradycardia, no murmur
• Abd-bs, soft , nt/nd
• Skin-warm and dry

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Neurological Exam

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

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GCS

• Eyes-1
• Verbal-1
• Motor-4

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NIH Stroke Scale
NIH Stroke Scale
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NIHSS Score

• Stroke scale 25

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CT Scan
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Key Clinical Questions

• What's the optimal ED management of a patient
  with ICH?
• What are the goals of BP management?
• Why is ICP important?
• What are the optimal strategies for managing ICP?
• What other treatment modalities are available to
  the ED physician?

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Key Clinical Questions

• Which ICH patient require surgery?
• How does hemorrhage volume affect mortality?
• What are the new therapies being tested for this
  disease process?

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NY Times
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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.

Update on management of intracerebral hemorrhage
Neurosurgery Focus 15 2003 1-6
14
Algorithm
Qureshi A, Tuhrim S Spontaneous Intracerebral
Hemorrhage NEJM, Vol 344, No 19 May 10, 2001
1450-1460
15
Intracranial Hemorrhage

• Diagnosis
• Treatment
• ICP
• BP management
• Medical management
• Neurosurgical indications
• New treatment modalities

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ICH Epidemiology

• 30 day mortality 30-40
• 50 of these in first 48 hours
• One-fifth of survivors are independent at 6
  months
• 7000 operations annually in USA to remove blood

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ICH Presentation

• Hypertension (90)
• Altered mental status (50)
• Headache (40)
• Seizures (6-7)

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ICH Diagnosis
CT scan is the most effective tool in the ED

• CT scan

CT scan is excellent for imaging blood
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Clinical Case ED Rx

• Patient starts to vomit
• B/P 266/122
• RSI
• Lidocaine 100 mgs
• Etomadate 20 mgs
• Succinylcholine 100 mgs
• Mannitol 150 ccs
• Elevate Head of Bed
• Hyperventilation to pCO2-30

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Clinical Case ED Rx

• Paralytics-Pancuronium 7 mg
• BP management-Nipride
• Steroids-Decadron 10 mgs

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Initial ED Therapy

• Resuscitation of the patient-regardless of ICP
• Assume elevated ICP in head injury/altered MS
  patient
• ABCs-as all good ED physician would do

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Key Concept

• Cerebral blood flow
• 1. Intracranial pressure
• Elevated when ICP gt20 mm Hg
• 2. Cerebral perfusion pressure
• CPPMAP-ICP
• Maintain CPP gt 70 mm Hg
• Example MAP 100, ICP 20
• CPP in above example 80 mmHg

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Increased ICP Risk

• Intracranial Pressure (ICP) considered a major
  contributor to mortality when elevated
• Correlation between elevated ICP and poor outcome
• Increased risk of
• Herniation
• Decreased Cerebral perfusion

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Increased ICP Treatment

• Controlling ICP is considered essential
• Osmotherapy
• Hyperventilation
• Barbiturate coma

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Clinical ICP Assessment

• For those without access to emergent ICP monitors
• Pupils size and reactivity
• Neurological status-deterioration vs. improvement

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NIH Stroke Scale
NIH Stroke Scale
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ICP Monitors

• GCS less than 9
• All patients whose condition is thought to be
  deteriorating due to elevated ICP

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
28
Osmotherapy

• Osmotherapy-Mannitol
• Reduces ICP by decreasing cerebral fluid volume
• Rebound effect-use less than 5 days
• Intermittent Bolus-not continuous infusion
• 0.5-1.0 mg/kg maintain serum osmolarity lt 310-320
  mOsm/L
• Renal failure
• Volume depletion (make sure patient has a Foley)

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HOB Elevation

• Elevate head of bed-decrease ICP
• Mechanical-helps drain blood by gravity
• Keep neck in neutral position
• Do not obstruct venous outflow
• Do not allow blood to pool in cranium, which may
  occur if patient is left laying flat

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Endotracheal Intubation

• Intubation-not required, but airway protection
  and adequate ventilation are necessary
• Rely on clinical suspicion, not GCS
• Decreases ICP by decreasing CBF
• pCO2 should be kept around 30-35
• Avoid PCO2 less than 30
• Decrease CBF to ischemia without further lowering
  ICP
• Beneficial effect of sustained hyperventilation
  is not proven

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Lidocaine

• 1.5 mgs/kg
• Depresses cough reflex
• Blocks increases in ICP of intubated patients
  with space occupying lesions
• Give 3 minutes before laryngoscopy

Lev, R, Rosen,Pp Prophylactic Lidocaine Use
Preintubation A review JOEM Vol 12 No 4 499-506
32
Paralytics/Sedation

• Recommended
• prevents increasing intrathoracic and venous
  pressures associated with coughing, suctioning,
  and bucking on ETT
• Avoids ICP spikes-elevated ICP correlated to poor
  outcome

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Barbituate Coma

• Lowers ICP via lowering Cerebral metabolism
• Use when other therapies fail
• No evidence of improved outcome

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BP Management

• Lower blood pressure to decrease risk of ongoing
  bleeding from ruptured small arteries
• Thus increasing hemorrhage volume
• Overaggressive treatment of blood pressure may
  decrease cerebral perfusion pressure and worsen
  brain injury
• Especially true with elevated ICP

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SBP and ICH Incidence
Incidence Rate/100,000
Systolic Blood Pressure (mmHg)
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BP Management

• Maintain blood pressure below a mean arterial
  pressure of 130 mm Hg in persons with a history
  of hypertension
• If there is an ICP monitor
• ICP should be kept lt 20 m Hg
• Cerebral perfusion pressure (MAP-ICP) should be
  kept gt 70 mm Hg

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
37
BP Management

• Labetalol
• Repetitive I.V. boluses of 20-80 mg q. 10 min or
  constant infusion of 0.5-2.0 mg/min
• Nicardipine
• 5-15 mg/hr I.V. infusion

Update on management of intracerebral hemorrhage
Neurosurg Focus 15 2003 1-6
38
Nipride

• Nipride
• 0.5-1.0 mics/kg/min
• Theoretically can increase cerebral blood flow
  and thereby intracranial pressure

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BP Management

• Avoid hypotension
• If systolic BP drops to less than 90 mmHg
• fluid boluses-isotonic saline or colloids
• Pressors
• Phenylephrine, dopamine, Norepinephrine

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
40
Hypotension

• Do not let Systolic BP fall below 90
• Hypoxemia
• Deleterious outcome 717 patients prospectively
  collected data set from Traumatic Coma Data bank
• May be more important than hypertension

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Cerebral Blood Flow
Neurology July, 2001 18-24
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Cerebral Blood Flow
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CBF Conclusions

• In patients with small to medium sized acute ICH,
  autoregulation of CBF was preserved with arterial
  pressure reductions.
• QureshiCritical Care Medicine. 27(5)965-971,
  May 1999-
• 18 mongrel dogs
• Reduction of MAP within normal autoregulatory
  limits of CPP had no adverse outcome on ICP or
  regional blood flow

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BP Management

• Treatment should be started within 6 hours of
  symptom onset
• A Prospective Multicenter Study to Evaluate the
  Feasibility and Safety of Aggressive
  Antihypertensive Treatment in Patients with Acute
  Intracerebral Hemorrhage
• Journal of Intensive Care Medicine, Vol 20, No 1
• Burke, Dorfman-not yet published

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Fever Management

• Elevated temperatures can increase the degree of
  ischemic injury.
• Etiologies include infection, neuronal injury,
  SIRS
• Studies have demonstrated increased morbidity and
  mortality in patients with sustained temperature
  elevation.
• Treat temperature gt 38.5 C
• Acetaminophen or a cooling blanket best options.

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Seizure Therapy

• Neuronal injury may lead to seizures
• Nonconvulsive seizures may contribute to coma in
  up to 10 of patients
• Consider prophylactic antiepileptic therapy in
  setting of ICH
• Lobar hemorrhage-35 seizure rate
• Fosphenytoin or phenytoin

Broderick Guideline for the Management of
Spontaneous Intracerebral Hemorrhage Stroke 4,
1999, 905-915
47
Seizure Therapy

• No consensus exists on when to withdraw
  anticonvulsant therapy
• If no seizure activity-withdraw at one month

Fewel Spontaneous Intracerebral Hemorrhage A
Review Neurosurg Focus 15 (4), 2003
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Medical Therapy

• Euvolemia
• Isotonic crystalloid solutions
• Electrolyte abnormalities
• Correct deficits
• Glucose management- gt140 start insulin

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Medical Therapy

• ABG
• Correct hypoxemia, hypercapnia
• Correct acid/base disorders
• Coagulopathy
• Correct INR
• Correct Platelet counts

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Steroids

• Controversial
• Three studies (159 patients)-no benefit
• Tellez H, Bauer RB Dexamethasone as treatment in
  cerebrovascular disease. 1. A controlled study in
  intracerebral hemorrhage. Stroke 4541546, 1973
  (40)
• Poungvarin N, Bhoopat W, Viriyavejakul A, et al
  Effects of dexamethasone in primary
  supratentorial intracerebral hemorrhage. N Engl J
  Med 31612291233, 1987 (93)
• Desai P, Prasad K. Dexamethasone is not
  necessarily unsafe in Primary Supratentorial
  Cerebral Hemorrhage. J Neurol Neurosurg
  Psychiatry. 199865799-800 (26)
• Neurosurgerical literature
• Use when evidence of vasogenic edema and mass
  effect

Update on management of intracerebral hemorrhage
Neurosurg Focus 15 2003 1-6
51
Blood Clot
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ICH Hemorrhage Volume

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

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(No Transcript)
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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

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(No Transcript)
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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 slice thickness in cm

L Schwamm Guidelines for Emergency Department
Management of Brain Hemorrhage 2, 2004
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Hematoma Volume Calculation

• Formula for volume of an ellipsoid
• 4/3? (A/2)(B/2)(C/2)
• Simplified ABC/2

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CT Scan
A (11cm)-greatest hemorrhage diameter B(4cm)-Diaem
ter at 90degrees C-2mm slices,8
slices 11x4x0.16/235.2 mls
B
A
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Prognosis

• Worse
• Volume gt 60 cm3 and GCS lt 9
• 91 dead at 30 days
• Patients with volume over 30 cm3 only 1 / 71
  independent at 30 days
• Intraventricular extension
• Better
• Volume lt 30 cm3 and GCS 9 or higher
• 19 dead at 30 days

(Broderick, Stroke)
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BP Hemorrhage Volume
Ohwaki, k Yano E Blood Pressure management in
Acute Intracerebral Hemorrhage Stroke
2004351364
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BP Hemorrhage Volume

• 76 patients
• Hemetoma enlargement in 16 patients
• Elevated BP increases the risk of hematoma
  enlargement

Ohwaki, k Yano E Blood Pressure management in
Acute Intracerebral Hemorrhage Stroke
2004351364
62
Rec Factor VIIa-Coumadin
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ED Patient Management

• Neurosurgery consulted
• EVD placed in the ED
• Patient taken to the OR for evacuation of
  hematoma
• BP-119/79 P-92 RR-12

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Patient Outcome

• Next day brain flow studies
• Patient declared brain dead
• Patient extubated

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ICH Surgical Outcome
Arch Neuro. 1990471103-1106
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Surgical Outcome
Arch Neuro. 1990471103-1106
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STICH Trial
Lancet 2005365387-97
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STICH Trial-Methods
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STICH Data
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STICH Trial-Outcome
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STICH Trial Outcome
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STICH Conclusion

• Patients with spontaneous supratentorial
  intracerebral hemorrhage in neurosurgical units
  show no overall benefit from early surgery when
  compared to initial conservative treatment

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ICH Surgical Indications

• Cerebellar hemorrhage gt 3 cm who are
  deteriorating or with brain stem compression and
  hydrocephalus from ventricular obstruction
• Vascular malformation if lesion is surgically
  accessible and patient has chance for good
  outcome
• Young patients with a moderate or large lobar
  hemorrhage who are clinically deteriorating

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Non-Surgical ICH Pts

• Small Hemorrhages (10 cm3)
• Minimal neurological deficits
• GCS lt 4 (excluding cerebellar hemorrhage with
  brain stem compression)

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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
Neurosurg Focus 15 2003 1-6
76
What Can We Do?

• Optimal medical management
• Stop the bleeding
• Factor VII
• Call your Neurosurgeon
• I have this patientyou do not need to come in

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Stroke Centers

• Hospitals should have systems in place to care
  for stroke patients
• ED, Radiology, Neurology/Neurosurgery, Primary
  Care, Rehab
• JACO lists Core Measures
• ASA, Dysphagia, DVT prophylaxis, TPA considered,
  Lipid profile, smoking cessation, plan for rehab,
  stoke education
• Similar to Cardiology

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Key Learning Points

• For management guidelines.
• Broderick Guideline for the Management of
  Spontaneous Intracerebral Hemorrhage Stroke 4,
  1999, 905-915
• Management and Prognosis of Severe Traumatic
  Brain Injury-a joint project of the Brain Trauma
  Foundation and the American Association of
  Neurosurgeons, 2000

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Key Learning Points

• CT scan is the most important tool in your
  diagnostic toolbox
• Manage blood pressure, noting that guidelines are
  variable
• Aggressively manage fever and seizures
• Consider hyperventilation and paralytics in
  setting of increased ICP and deterioration

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Key Learning Points

• Most ICH patients are non-surgical
• Consult your neurosurgeon early
• Steroids-no benefit
• There are promising new therapies such as Factor
  VII on the horizon

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Questions?? www.ferne.orgferne_at_ferne.orgMarc
Dorfman, MDmdorfman_at_reshealthcare.org773 792
7921
ferne_acep_2005_spring_dorfman_ich_edrx
3/2/2005 94512 AM
Marc Dorfman, MD, FACEP, MACP