Intracranial Hemorrhage. Objectives. What Do Need to Know?

Transcription

1 Intracranial Hemorrhage What Do Need to Know? Kerry Brega, MD Associate Professor of Neurosurgery University of Colorado Objectives Know the common types of ICH. Know how they can be differentiated. Know when to suspect an ICH. Know the necessary immediate medical management. Be aware of the common early complications of ICH. Hypertensive hemorrhage Amyloid angiopathy Hemorrhagic conversion of CVA Vascular malformation/ Aneurysm/ Cavernoma Hemorrhagic tumor Subdural hematoma Venous sinus thrombosis

2 Diagnosis SUSPECT ICH WHEN--- Headache that is prominent complaint. 80% with ICH and only 25%with ischemic CVA Among patients who can respond, 85% with aneurysmal SAH report sudden onset of the worst headache of their lives! Nausea and vomiting 50% with ICH and 2% with ischemic CVA Decreased level of consciousness- These symptoms reflect increased intracranial pressure and are common to all types of ICH Diagnosis ICH CT will identify and help classify the ICH etiology. Each ICH type has a recognizable pattern. HTN- Small/end vessel (perforators) or microaneuryms (Charcot-Bouchard) The bleeds are commonly located in Putamen, Thalamus, Pons, Cerebellum. Amyloid Angiopathy- Protein deposition in small to medium cortical and leptomeningial vessels. (Not associated with systemic amyloidosis.) These bleeds tend to be more cortically located. HTN Hemorrhage Location Neurosurg Focus 15(4): Article 1; 2003

3 Hypertensive Stroke Hypertensive Stroke Cerebral Amyloid Angiopathy Can present single or mulitple spontaneous intracerebral hemorrhages or as progressive dementia. Usually in patients >60 years of age, thereafter increasing prevalence. Younger patients in familial types. Correlation with Alzheimer Disease? 30-40% recurrence rate on intracerebral hemorrhage Hemorrhage usually in frontal or parietal cortical or subcortical matter. Infrequently in basal ganglia, cerebellum or brain stem. EMedicine.com

4 Amyloid Angiopathy Hemorrhagic transformation of ischemic CVA Occurs in about 10% 2 types petichial or parenchymal Petichial more common confined to the area of ischemia this may be due to leakage of blood cells through damaged capillaries without frank vessel rupture Parenchymal hematomas are more likely due to vessel rupture and are larger

5 Hemorrhagic MCA infarct Subarachnoid Hemorrhage 42 year old woman presents to clinic with history of sudden onset of the worst headache of her life 2 days ago. Headache largely resolved. Sentinel headaches as high as 20%. Ask about associated symptoms- Increased ICP and meningismus. nausea/vomiting 77% stiff neck- 35%, photophobia brief loss of consciousness- 53% focal neurologic deficits including the cranial nerves radicular type leg pains or back pain

6 Work up for SAH CT scan reliable within first 3 days, the earlier the better. But even if done within first 48 hours may miss up to 5%. With a negative CT but a suspicious history or exam -> CTA or LP. CTA should reliably identify aneurysms above 2 mm in size. Role of CTA varies by institution. Role of lumbar puncture varies by institution but recommended if CT negative and history is concerning. Presence of xanthrocromia Subarachnoid SAH/ CTA

7 Hemorrhagic Tumor Case 1 Treatment Hurry! Treatment requires the same vigilance as the ischemic strokes being evaluated for tpa. 73% will increase in size over 3 hours. Up to 38% have hematoma expansion > 1/3 on repeat CT within 3 hours! Size matters! Mortalities range for 35-52% Approximately half in the first 48 hours! Coagulopathies Patients taking oral anticoagulants (OACs) 12% to 14% of patients with ICH Goal is to get INR to 1.4 within 2 hours Patients with qualitative or quantitative platelet abnormalities. Goal is >100,000 Recognition of an underlying coagulopathy provides an opportunity to target correction in the treatment strategy, Xa inhibitors and direct thrombin inhibitors

8 Review of Coagulation Cascade Reversal of Oral Anticoagulants: Warfarin Vitamin K antagonist inhibits coagulation factors II, VII, IX and X Half-life: h (variable) Urgent reversal à reduce mortality, limit hemorrhage expansion and improve outcomes Goal INR <1.5 Reversal Agents: Vitamin K (IV > PO > subq) FFP 4-factor PCC (Kcentra) Neurocrit Care. 2016; 24: Xa Inhibitor Half-life Direct Xa Inhibitors Rivaroxaban (Xarelto)* 5-9 h, h in elderly Apixaban (Eliquis) Edoxaban (Savaysa) Fondaparinux *DH preferred DOAC 8-12 h h h } No reversal agent currently available } Andexanet alpha } Consider 4-PCC 1500 units } No standard dose recommendation in literature } Doses up to 50 units/kg Neurocrit Care. 2016; 24:6-46

9 Reversal of Oral Anticoagulants: Direct Thrombin Inhibitor Dabigatran (Pradaxa) Half life: 12-17h Lab test: n/a Consider INR, aptt, Thrombin Time, ACT Reversal Agent: Idarucizumab (Praxbind) Monoclonal antibody that binds free and thrombin-bound dabigatran Onset: Immediate Duration: at least 24 hours Dosing: 5g IVP over 10 minutes (available as 2.5g in 50mL vials) 25 Neurocrit Care. 2016; 24:6-46. Dabigatran Package Insert Seizure Prophylaxis 2010 guidelines recommended against it but there has been no change in use. Levetiracetum- fewer side effects- Study showed that dilantin associated with worse outcomes at 3 months but not levetiracetum. Some studies with it showing improved cognitive outcomes at discharge and fewer seizures. Typical dose 500 BID Taylor S, Heinrichs RJ, Janzen JM, Ehtisham A. Levetiracetam is associated with improved cognitive outcome for patients with intracranial hemorrhage. Neurocrit Care. 2011;15:80-84 Szaflarski JP, Sangha KS, Lindsell CJ, Shutter LA. Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care. 2010;12: Xa Inhibitors Andexxa-4 Ongoing multicenter trial Bind Xa inhibitors so they cannot interact with Factor Xa

10 Blood Pressure Blood pressure (BP) is frequently ( often markedly) elevated in patients with acute ICH Stress activation of the neuroendocrine system Sympathetic nervous system Renin-angiotensin axis Glucocorticoid system Increased intracranial pressure Hypertension may contribute adverse outcomes due to Hematoma expansion- There is more than double the risk of death and dependency in patient with SBP > range in the first 12 hours. Perihematoma edema Blood Pressure Blood pressure (BP) is frequently ( often markedly) elevated in patients with acute ICH Stress activation of the neuroendocrine system Sympathetic nervous system Renin-angiotensin axis Glucocorticoid system Increased intracranial pressure Hypertension may contribute adverse outcomes due to Hematoma expansion- There is more than double the risk of death and dependency in patient with SBP > range in the first 12 hours. Perihematoma edema Treatment of SAH All the same considerations apply. Treat intracracranial pressure Control blood pressure Reverse any coagulopathy Prevent Re-Bleed/ secure the aneursym ASAP Clipping of coiling

11 Generic ICH orders Q 1 hour neuro checks- tell the nursing staff what you are looking for. Remember that agitation and increases in BP are early signs of increased intracranial pressure. HOB 30 degrees Control BP generally < 140 systolic Correct coags ASAP Prophylaxis for seizure Kepra (lobar bleeds) treat fevers Fluids/O2 to maintain normal status When things are going badly Neurologic decline Protect airway/ control BP Expansion of the clot #1 MUST REPEAT A CT SCAN Seizure Hydrocephalus Vasospasm Other metabolic Obstructive Hydrocephalus

12 Craniotomy and supratentorial hematoma evacuation Cochrane Database of Systematic Reviews 2007 Issue Case 1 HPI: 67 y.o. man in A fib on Xeralto, presents to ED with history of headaches for 2 days and trouble with vision. PMHx: A fib, HTN, PE: headache not severe 189/100, HR 87 A & O X3, no motor or sensory deficits Right homonymous hemianopsia Case 1

13 Case 1 Immediate management? While in ED develops significant decline in mental status? Treatment? Additional work-up? Case 1 Case 2 HPI: 74 y.o. man with artificial valve, pacer, DM, HTN, OSA on coumadin. Had a fall about a month ago without LOC. Has progressively increasing headaches and balance problems. Fell twice over last week. PE: A & O X 3, headache 5/10, pronation with LUE, otherwise intact

14 Case 2 Case 2 Case 3 32 y.o. female with sudden onset of left arm weakness and poor coordination 12 hours prior to admission. Sx s relatively stable since. (+) history of HA starting 3-4 days ago like a band across my forehead. HA slowly progressive over last 24 hours with onset of nausea, stiff neck and photophobia. Seen in outside ER with CT scan

15 CT (+) Gad