management of intracerebral hemorrhage navaz karanjia, md director of neurocritical care university...
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MANAGEMENT OF INTRACEREBRAL HEMORRHAGENavaz Karanjia, MD
Director of Neurocritical Care
University of California – San Diego
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Intracerebral Hemorrhage
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Intracerebral Hemorrhage
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Intracerebral Hemorrhage
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Neurocritical Care Management of Intracerebral Hemorrhage Epidemiology
10-15% of all strokes, 50-70,000 cases/yr in US Presentation
Headache, neurologic deficit Outcomes
40% 30-day mortality Reduced by 17% by an NCCU/neurointensivist
20% independent at 6 monthsImproves by 21% by an NCCU/neurointensivist
Mirski M, Chang CW, and Cowan R. J Nsurg Anesth 2001; 13(2): 83-92.
Lancet Neurol. 2010 Feb;9(2):167-76. doi: 10.1016/S1474-4422(09)70340-0
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Intracerebral Hemorrhage
Causes of ICH
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Intracerebral Hemorrhage
Common locations for hypertensive ICH
Thalamus Cerebellum Pons Basal Ganglia
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Intracerebral Hemorrhage
Clinical course and complications
Tissue dissection, displacement, increased ICP (immediate)
Hematoma expansion (immediate ->36h)HydrocephalusNeurohemoinflammation/Cerebral edema (day 2-5)SeizuresCentral fever
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Intracerebral Hemorrhage
Hematoma expansion72% have some hematoma expansion over 24h
38% have clinically significant expansion within 24h
Within 1 hr in 26% of casesWorsens outcome
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Neurocritical Care Management of Intracerebral Hemorrhage Preventing hematoma expansion (INTERACT,
ATACH) IMMEDIATE BP control reduces expansion 30%
Target SBP 140-150 with nicardipine drip or labetalol/hydralazine IVP WITHIN 10 MINUTES
IMMEDIATE coagulopathy reversal FFP, PCC (KCentra) within 30 minRecheck coags 15 min post PCCPlatelets if <100,000 or TEG abnlNOT factor VII (FAST trial)Time to reversal is being tracked
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PCC (Profilnine) Pathway
History of thrombotic event in past 6 wks? (DVT, PE, trauma, ischemic stroke, ACS, mesenteric ischemia, etc)Major surgery within 6 weeks? Heparin induced thrombocytopenia (HIT)?
UCSD Reversal Protocol for Spontaneous Intracerebral Hemorrhage with INR > 1.4
• INR 2-4: infuse 25 units/kg body weight* Profilnine over 5 min, not to exceed 2ml/min
• INR >4: infuse 40 units/kg body weight* Profilnine over 10 minutes, not to exceed 2ml/min
• Repeat INR 15 minutes after infusion complete. If INR not at target, repeat q15 min x2 until INR at target. Once INR ≤1.4, repeat INR every 6 hrs for 24 hrs. If INR > 145, give another 10mg vitamin K IV/PO and consider 2 more units FFP.
• If INR does not reach target in 45 minutes, consider Factor 7, 20-40 mcg/kg (1-3mg) IV x 1
At 24 hrs, repeat dose of Vitamin K 10 mg IV/PO * in obese patients, base dose on a maximum weight of ideal body weight + 20% ***
Check the following labs at 1 hr and q6 hrs after completion of PCC infusion: PT/INR, EKG and Cardiac enzymes, Fibrinogen
INR > 2.0
• STAT Labs: PT/INR, PTT, fibrinogen, platelets, CBC, Type and Screen, troponin• If crash craniotomy considered, type and cross 2U PRBC
• Give vitamin K 10mg IV stat; if IV not available, give 10mg PO• Transfuse 2U FFP stat over 30 min. If type&screen will take >30 min and INR>2, transfuse 2U
uncrossmatched FFP. If pt cannot tolerate FFP due to volume overload, use PCC+Factor 7 20-40mcg/kg (1-3 mg)
FFP Pathway
• Immediately give 2 more units FFP • Repeat coags upon completion of infusion• If INR still >1.4, 2 more units FFP • If still > 1.4, consider PCC and consult hematology• Once INR ≤1.4, repeat INR q4-6 hrs for 24-48 hrs
Can patient tolerate more FFP (volume status)?YES
NO YES
INR 1.4 – 2.0
NO
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Stat labs at 15 min and q6 hours after completion of PCC infusion: PT/INR, TT, EKG, cardiac enzymes, fibrinogen, anti-Xa level. If TT or PT/INR is still prolonged AND patient still bleeding/extreme risk of hematoma expansion, consider repeating Profilnine dose or giving Factor 7, 20-40mcg/kg (1-3mg) IV x1
UCSD Reversal Protocol for Spontaneous Intracerebral Hemorrhage on Dabigatran, Rivaraoxaban, or Apixaban
• STAT labs: PT/INR, fibrinogen, platelets, CBC, PTT, TT, anti-Xa level , Type & Screen• If crash craniotomy considered, type and cross 2U PRBC
IF ON DABIGATRAN (direct thrombin inhibitor )
and TT prolongedIF ON RIVAROXABAN or APIXABAN (factor Xa inhibitor)
and PT/INR is prolonged or anti-Xa level elevated
IF ingestion within 2 hrs, give one dose activated charcoal orally
• infuse 25 units/kg (+/- 10%) body weight* PCC (Profilnine) over 5 minutes, not to exceed 2ml/min• Transfuse 2 units FFP STAT. If type and screen will take >30 min, transfuse 2 units uncrossmatched FFP.
Emergent dialysis may be considered in certain circumstances (renal failure, overdose); ~ 65% removed by hemodialysis
Dabigatran t ½ = 14 hrs (up to 34 hrs in severe renal impairment)
Rivaroxaban and Apixaban are NOT dialyzable
Rivaroxaban t 1/2 = 9 hrs (longer in renal impairment)Apixaban t ½ = 12 hrs (longer in renal impairment)
* in obese patients, use maximum weight of ideal body weight + 20%
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Neurocritical Care Management of Intracerebral Hemorrhage Acute obstructive hydrocephalus
occurs in 50-70% of IVH patients treat with emergent EVD Intraventricular tPA for IVH clears IVH faster (11.4-
>2.6 days), likely reduces hydrocephalus/need for VP shunt, ? mortality/outcomes (CLEAR-IVH)
Huttner HB, Tognoni E et al. Eur J Neurol. 2008;15(4):342.
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Intracerebral Hemorrhage
Neurohemoinflammation/cerebral edemaPeaks days 2-5Exacerbated by fever and seizureMedical cerebral edema treatment ((hypertonic saline, normothermia, seizure control, ventilation control)
Surgical/endoscopic clot removal
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Neurocritical Care Management of Intracerebral HemorrhageSurgical clot removal (MISTIE II, STICH II trials)Endoscopic for deep clots
Improves good outcome 20% 34%
Open for all superficial clotsReduces mortality (STICH II)
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Neurocritical Care Management of Intracerebral Hemorrhage
MISTIE II
Hanley, D et al. Mistie II Trial Results: 365 day outcome and cost-benefit. ISC 2013 Late Breaking Newshttp://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_449055.pdf
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Seizure control33% of altered ICH patients have seizures, most are nonconvulsiveSeizures worsen ICP, midline shiftAll altered ICH pts should receive
continuous EEG monitoring (Class I, LOE B )
Claassen et al. Anesthesia Analg. Vol. 109, No. 2, August 2009
2012 Neurocritical Care Society Guidelines:
Indications for Continuous EEG
Monitoring
Neurocritical Care Management of Intracerebral Hemorrhage
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Neurocritical Care Management of Intracerebral Hemorrhage
Vespa et al Neurology 2003
Seizures after ICH leads to worsening midline shift
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Neurocritical Care Management of Intracerebral Hemorrhage
Vespa et al Neurology 2003
Seizures after ICH leads to worsening midline shift
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Neurocritical Care Management of Intracerebral Hemorrhage
Vespa et al Neurology 2003
Seizures after ICH leads to worsening midline shift
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Intracerebral Hemorrhage
Antiepileptics are indicated ONLY if the patient demonstrates evidence of seizure clinically or on EEG (prophylactic AED’s worsen outcome, OR mRS>3 = 9.8).
Class I, LOE B
AED PROPHYLAXIS?
Naidech et al, Stroke 2009
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Intracerebral Hemorrhage
Central feverOccurs in 70% of patientsIncreases cerebral metabolic rate, ICP, and midline shiftNormothermia should be maintained and fever treated aggressively, using antipyretics and intravascular/surface cooling devices if needed (Class I, LOE B recommendation)
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Neurocritical Care Management of Intracerebral Hemorrhage
Normothermia, glycemic control, dysphagia screening
Lancet 2011: For all hemorrhagic and ischemic stroke patients, implementation of an RN protocol to treat any temp≥37.5, glycemic control, dysphagia screening decreases death/dependence 58% -> 42%, NNT 6.4
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Intracerebral Hemorrhage
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Neurocritical Care Management of Intracerebral Hemorrhage