Intracranial Hemorrhage

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Intracranial Hemorrhage
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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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NY Times
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Key Clinical Questions

• What are the most common etiologies and locations
  of ICH?
• What are the goals of BP management?
• What are the optimal strategies for managing ICP?
• What other treatment modalities are available to
  the ED physcian?

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Key Clinical Questions

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

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Intracranial Hemorrhage

• Epidemiology
• Etiology
• Diagnosis
• Treatment
• BP management
• Neurosurgical indications
• New treatment modalities

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ICH Epidemiology

• 30 day mortality 35-52
• 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 Types

• Epidural
• Subdural
• Subarachnoid
• Intraparencymal
• Intraventricular
• Cerebellar

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Hypertensive ICH

• Hypertension
• Essential
• Eclampsia
• Sympathomimetics
• Cocaine
• Amphetamines
• Phenylpropanolamine

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Hypertensive ICH

• 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, gaze paresis

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Other ICH Etiologies

• Amyloid
• Trauma
• Vascular malformation-Avm, cavernoushemangiomas
• Aneurysm
• Tumor
• Coagulopathy
• Vasculitis

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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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ICH Rx Key Concepts

• Two key concepts
• Intracranial pressure
• Elevated when ICP gt20 mm Hg
• Cerebral perfusion pressure
• CPPMAP-ICP
• Must maintain ICP gt 70 mm Hg
• Example MAP 100, ICP 20
• CPP in above example 80 mmHg

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Increased ICP Treatment

• Intracranial Pressure (ICP) considered a major
  contributor to mortality when elevated
• Controlling ICP is considered essential
• Osmotherapy
• Hyperventilation
• Barbiturate coma

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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 pCO25-30

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Clinical Case ED Rx

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

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Osmotherapy

• Osmotherapy-Mannitol
• Reduces cerebral edema by decreasing cerebral
  fluid volume
• Rebound effect-use less than 5 days
• 20 solution
• 0.5-1.0 mg/kg maintain serum osmolarity 310-320
  mOsm/L

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HOB Elevation

• Elevate head of bed-decrease ICP
• Mechanical-helps drain blood by gravity
• Does 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
• Hyperventilation decreases ICP
• pCO2 should be kept around 30-35
• Beneficial effect of sustained hyperventilation
  is not proven

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Paralytics

• Recommended in order to prevent increasing
  intrathoracic and venous pressures associated
  with coughing, suctioning, and bucking on ETT,
  all of which may cause ICP spikes
• ICP spikes associated with poorer outcome,
  especially in setting of elevated ICP

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ICP Monitors

• AHA recommends ICP monitors in patients with a
  GCS less than 9 and all patients whose condition
  is thought to be deteriorating due to elevated ICP

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BP Management

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

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BP Management

• AHA recommends blood pressure be maintained 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
• Cerbral perfusion pressure (MAP-ICP) should be
  kept gt 70 mm Hg

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BP Management

• Avoid hypotension
• If systolic BP drops to less than 90 mmHg,
  consider judicious fluid boluses and/or start
  pressors

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BP Management

• Labetalol
• 20 mg IV, followed by 40 80 mg IV q10 min
• Titrate to BP or max 300 mgs admin
• Nipride
• 0.5-1.0 mics/kg/min
• Theoretically can increase cerebral blood flow
  and thereby intracranial pressure

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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 temperture 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 neurocritical patients
• Consider prophylactic antiepileptic therapy in
  setting of ICH
• Lobar hemorrhage-35 seizure rate
• Fosphenytoin or phenytoin

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Medical Therapy

• Euvolemia
• Isotonic crystalloid solutions
• Electrolyte abnormalities
• Correct deficits
• Acid/base disorders
• Correct them if present
• Steroids-no benefit

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Blood Clot
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ICH Hemorrhage Growth

• Until recently, bleeding in patients with ICH was
  thought to be completed within minutes of onset
• Several small studies describe a few patients who
  had an increase in the volume of parenchymal
  hemorrhage on repeated CT scans

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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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ICH Hemorrhage Growth

• Early Hemorrhage Growth in Patients With
  Intracerbral Hemorrhage
• Brott, Broderick, Kothari
• Stroke Vol 28, 1 January 1998

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ICH Growth Study Purpose

• Prospectively determine how frequently early
  growth of intracerebral hemorrhage occurs and
  whether this early growth is related to
  neurological deterioration

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ICH Growth Study Design

• 102 patients
• CT scan 3 hours and 24 hours
• 38 patients with gt 33 growth in volume of
  parenchymal hemorrhage

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ICH Growth Conclusions

• 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

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ICH Factor VIIa Study

• Safety and Feasibility of Recombinant Factor VIIa
  for Acute Intracerebral Hemorrhage
• Mayer, Nikolai, Brun
• Stroke, Jan 2005, 36(1) p74-9

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ICH Factor VIIa Study Purpose

• Factor VIIa-promotes clotting-know to do so in
  hemophiliacs
• Activated factor VII promotes hemostasis at sites
  of vascualr injury and may minimize hematoma
  grwoth in ICH

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ICH Factor VIIa Study Design

• 48 subjects
• Randomized double blind placebo controlled
• Escalating doses of factor VII
• Endpoint-frequency of adverse events

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ICH Factor VIIa Study Conclusion

• Phase II trial
• No major safety concerns
• Larger study needed to determine if factor VII
  can safely and effectively limit ICH growth

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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 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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Key Learning Points

• ICH is a dynamic, not a static process
• Hemorrhage volume can increase over time
• 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_aaem2005_dorfman_ich_cdformat.ppt
2/14/2005 702 PM
Marc Dorfman, MD, FACEP, MACP