Management of intracranial hemorrhages

Management of intracranial hemorrhages

OBJECTIVES

OBJECTIVES Importance and causes. Management : general measures.

elevated BP

clot stabilization.

cerebral edema and elevated ICP

seizure prophylaxis

role of surgical procedures

Importance and Causes Counts for 8-11% of all acute strokes. Twice as common as SAH. 50% mortality at 30 days. Only 1 in 5 living independently at 6m. Incidence higher in men than women.

Importance and Causes Hypertensive hemorrhage.( basal ganglia )

Amyloid angiopathy. (lobar hmg, drugs)

AVM , anticoagulants and tumors.

Management: General Measures Suspicious ICH >>>> CT and ICU.

Airway protection.

30 degree head elevation.

Management: elevated BP According to Rosen’s 7th ed:

1. Rx more aggressive with ICH than ischem

2. Parenteral sys >160-180, diast >105

3. Most common agent nitroprusside as titratable, rapid and has no effect on mental status BUT arterial cath ,? Vasodilate cereb vessel.

Management: elevated BP Two prospective, randomized, controlled

trials INTERACT and ATACH have NOT demonstrated change in outcome with intensive BP management.

Management of high BP  Recommended guidelines from the AHA for treating elevated BP in spontaneous ICH

If SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of blood pressure with continuous intravenous infusion, with frequent blood pressure monitoring every 5 min.

If SBP is >180 mm Hg or MAP is >130 mm Hg and there is evidence of or suspicion of elevatedICP, then consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous medications to keep cerebral perfusion pressure >60 to 80 mm Hg.

If SBP is >180 mm Hg or MAP is >130 mm Hg and there is no evidence of or suspicion of elevated ICP, then consider a modest reduction of blood pressure (e.g., MAP of 110 mm Hg or target blood pressure of 160/90 mm Hg) using intermittent or continuous intravenous medications to control blood pressure; clinically reexamine the patient every 15 mins

Management of high BP IV medications may be considered for control of elevated BP

in patients with ICH as recommended by the AHA

Labetalol 5–20 mg every 15 mins2 mg min-1 (maximum 300 mg/day)

Nicardipine 5–15 mg hr Esmolol250 μg kg-1 IVP loading dose25–300 μg kg-1 min Enalapril1.25–5 mg IVP every 6 hrs Hydralazine5–20 mg

Management: Clot Stabilization The goal of ICH management.

(Efficacy and Safety of a Fvii for acute ICH) used 80 microg/Kg within 3h of ICH

successfully reduced clot growth BUT failed to demonstrate reduction in severe disability and death.

So R factor viia use still investigational.

Management: Clot Stabilization Pts on warfarin:

1. INR reversal takes many hours with Vit. K or FFP

2. The use of these agents as precoagulants complexes and Fviia can reverse INR in mnts.

3. Factor vii,prothrombin complex concentrated and FFP in warfarin-related ICH started on 2008 still going on.

Remember In all ICH pts, there is 1.6% risk of DVT

Prophylaxis should be used with 24h when clot is stopped and BP is stable.

40mg OD daily considered safe.

Management: high ICP Cerebral edema and high ICP is apredector

of mortality in ICH. Options; CONTROLLED hyperventilation

mannitol

hypertonic saline Not to be used prophylactically. What about steroids?!!

Management: high ICP

For refractory cases:

1. Pharmacologically induced coma, high dose of propofol or phenopental. (data are lacking to support its effectiveness).

2. Hypothermia.

Management : hypothermia Efficacy in improving outcome in pts with

hypoxic-ischemic brain injury as a result of cardiac arrest is well established.

Few small pilot studies evaluate it in ischemic stroke.

No controlled trials in hemorrhagic stroke.

Management: hypothermia Promising BUT:

1. need high quality critical care to start immediately in ED, so rapidly induced within 3-6h.

2. it accompanied by complications like infection and cardiovascular complications.

Management: seizure prophylaxis Seizure activity can cause:

1. Neuronal injury.

2. Elevation of ICP.

3. Destabilized of an already critically ill pt.

4. Non convulsive seizure contribute to coma in 10% of neuro ICU pts.

So fosphenytoin 18mg/kg considered prophyl

Management: seizure prophylaxis In absence of fits, antiepileptics can be

stopped in 2-4 wks.

The use of prophylactic antiepileptic in basal and infratentorial hmgs seem unnecessary.

Role of surgery Surgery is NOT beneficial in most ICH cases

except for cerebellar hmg. The International Surgical Trial in Intracerebral

Hemorrhage (ISTICH) suggested that there was no clinical benefit from conventional surgical clot evacuation when compared with conservative medical management in acute ICH .

A new clinical trial (STICH 2) is ongoing to test the hypothesis that minimally invasive surgical evacuation of cortical clots may be beneficial

References ROSEN’S EMERGENCY MEDICINE 7THed American Journal of Surgery,April/2008. Critical Care Medicine,July/2009. Critical Care Medicine,March/2010. Annals of Emergency Medicine. Up-To-Date

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