Cyrus K. Dastur, MD Assistant Professor

Director, Neurocritical Care Departments of Neurology and Neurological Surgery

UC Irvine

Acute Care of Patients with Intracerebral Hemorrhage

Declarations

• None

Definitions

Intracranial Hemorrhage (ICH) – Subarachnoid Hemorrhage (SAH)

– Subdural Hematoma (SDH)

– Epidural Hematoma (EDH)

– Intraventricular Hemorrhage (IVH)

– Intracerebral/Intraparenchymal Hemorrhage (ICH/IPH)

Subarachnoid Hemorrahge

Subdural Hemorrhage

Epidural Hemorrhage

Epidural vs Subdural

Intraventricular Hemorrhage

Intracerebral/Intraparenchymal Hemorrhage

Intracerebral/Intraparenchymal Hemorrhage

Diagnosis

• History, History, History! – Time & activity at onset – Rapidity of deficits – LOC, seizure, fall

• Physical Exam • Tests

– EKG – CXR – Neuroimaging

• Non-contrast CT exam of brain

• CT Angiography • MRI of brain

Labs

• CBC with platelets

• BMP

• PT/INR

• PTT

• Serum Glucose

• Pregnancy Test

• Toxicology Screen

• Troponin

General Medical Management

Blood Pressure Management

• Initial Goals – Systolic Blood Pressure < 140

mmHg

– Minimum MAP > 65 mmHg

– Cerebral Perfusion Pressure >55 mmHg

CPP = MAP – CPP

• Initial Management – Hold oral BP meds – Short acting agents

• Labetalol • Hydralazine • Enalaprilat • Nicardipine • Esmolol

Figure 1. Early hematoma growth in a 48 year-old chronically hypertensive woman.

Mayer S A Stroke. 2007;38:763-767

Copyright © American Heart Association, Inc. All rights reserved.

• ATACH I (2004-2008) – Pilot study – Showed safety of early aggressive BP lowering to

goal SBP<140 mmHg

• ATACH II (2012 – ongoing) – Multicenter, randomized Phase III trial – Early aggressive treatment to SBP<140 vs

SBP<180 mmHg – Primary Endpoint – reduce death & disability at 3

months after ICH by at least 10%

Coagulopathy Management

• Coagulation factor deficiency – FFP, CPP, PCC, Factor VII

• Warfarin associated coagulopathy – FFP, PCC, Factor VII

– IV Vit K

• Severe thrombocytopenia – Platelet Transfusion

Complications of ICH CNS Complications • ICH growth/expansion • IVH extension and Hydrocephalus • Raised intracranial pressure • Cerebral edema • Autonomic dysfunction • Seizures • Neurological Deficits

Non-CNS Complications • Cardiac

– Troponin leak, EKG changes, AMI, Takotsubo Cardiomyopathy

• Pulmonary – Aspiration PNA, respiratory failure,

CNS breathing patterns, ARDS, neurogenic pulmonary edema

• GI – Ulcer, GI hemorrhage, illeus

• Neuroendocrine – hyponatremia, relative adrenal

insufficiency • Heme

– DVT, PE • Skin

– Decubitus Ulcers

Cerebral Edema/ICP management

• When to place EVD? – GCS <8

– Clinical evidence of transtentorial herniation

– Significant IVH or hydrocephalus

• CPP goal 50-70 mmHg may be reasonable

Figure. Intracranial pressure treatment algorithm.

Morgenstern L et al. Stroke 2010;41:2108-2129

Copyright © American Heart Association, Inc. All rights reserved.

Surgery for ICH

• Majority of patients - usefulness of surgery unclear

• Exceptions – Cerebellar ICH

• Deteriorating clinically • Have brainstem compression • Obstructive hydrocephalus

– Lobar clots >30 ml & within 1cm of surface • Stereotactic/endoscopic aspiration with or

without thrombolytics – Investigational only at current time.

Glucose Management

• High glucose on admission associated with worse outcomes in ICH patients – Unclear whether tight glucose control (80-110

mg/dL) is beneficial, and may be harmful

• Normoglycemia should be maintained

• Hypoglycemia should be avoided

Seizures and Antiepileptics

• Clinical seizures should be treated

• Continuous EEG probably indicated if depressed mental status out of proportion to degree of brain injury

• Prophylactic anticonvulsant medications should NOT be used.

Fever Management • Fever is not uncommon • Clear association with worse outcome • Aggressive treatment

– antipyretics, surface cooling, cold saline, intravascular cooling catheter

Hematoma Volume

• ABC/2 rule

• A x B x C / 2

• A & B = diameters of hemorrhage (in cm)

• C = # of slices x slice thickness (in cm)

• (3 cm x 3 cm x (3 slices x 0.5cm)) / 2 = 13.5/2 = 6.75 cm3

ICH Score

The ICH Score and 30-day mortality.

Hemphill J C et al. Stroke. 2001;32:891-897

Copyright © American Heart Association, Inc. All rights reserved.

DNR Orders

• Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recom- mended. – Patients with preexisting DNR orders are not included in

this recommendation. • Current methods of prognostication in individual

patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders.

• Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.

Summary

• Different types of ICH

• High morbidity/mortality disease

• ABCs – BP management

– Reversal of anticoagulation

• Avoid early prognositication