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
