SPONTANEOUS INTRACEREBRAL HEMORRHAGE

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1 SPONTANEOUS INTRACEREBRAL HEMORRHAGE

2 Intracerebral hemorrhageis an acute and spontaneous extravasationof blood into the brain parenchyma that may extend into the ventricles and subarachnoid space.

3 It is common: cases per people per year 10% ~ 15% of all cases of stroke 6 month mortality is 30-50%

4 Primary (78% ~ 88%) Chronic hypertension Amyloid angiopathy Secondary Vascular abnormalities (AVM, aneurysm) Tumor Coagulopathy

5 Coagulation disorders Anticoagulation /Thrombolytic therapy Hemorrhagic transformation of cerebral infarct Leukemia Thrombocytopenia Delayed post-traumatic Post-operative Carotid endarterectomy Craniotomy for evacuation SDH Craniotomy for excision AVM

6 Malignant Glioblastoma multiforme Lymphoma Metastasis (melanoma, choriocarcinoma, renal cell carcinoma, bronchogenic carcinoma) Benign Meningioma Pituitary adenoma Hemangioblastoma Acoustic neuroma Cerebellar astrocytoma

7 ICH in young Rp. AVM 30 % Undet. 24% HTN 15% Aneurym 10% Drug Abuse 7% 15 Tumor 4% Moyamoya 2% 24

8 Nonmodifiable Modifiable Male sex Hypertension Age Heavy alcohol consumption Asian and African Americans Japanese Hypercholesterolemia

9 Accounts for 60-70%of ICH Theory: Chronic hypertension causes degeneration, fragmentation and fibrinoid necrosis of small perforating arteries Predisposes to rupture

10 CHARCOT-BOUCHARD ANEURYSMS BADJATIA AND ROSAND, INTRACEREBRAL HEMORRHAGE. THE NEUROLOGIST, VOL. 11, NO. 6: NOVEMBER 2005 Discrete arteriolar microaneurysms Most common in the distal portions of medium and small arterioles

11 Deposition of amyloid β peptide in small and medium sized blood vessels Results in fibrinoid necrosis and microaneurysm formation Prevalence increases with age from ~ 9% in age to 58% in age >90 Lobar haemorrhages Chances of rebleed: 21% in 2 yrs

12 Primary-immediate effects Hemorrhage growth Increased ICP Secondary effects Edema Ischemia Progression of hematoma Brottet al: 103 pts 26% within 1 hours, 38% within 20 hours Acute hypertension, local coagulation deficit may be associated Brott, Stroke 1997;28:1-5

13 Early Presentation Irregular shape Liver disease Hypertension Hyperglycemia Alcohol use Hypofibrinogenima Priorities for Clinical Research in ICH: NINDS ICH Workshop; Stroke March 2005

14 Volume more than60 cm3 Deep-93% Lobar-71% Volumes cm 3 Deep-60% Lobar-60% Cerebellar-75% Volumes less than 30 cm3 Deep-23% Lobar-7% Cerebellar-57% Broderick: Volume of ICH; Stroke Vol 24, No 7

15 Classic clinical presentation: Onset of sudden focal neurological deficit which progresses over minutes to hours 50% present with headache /vomiting LOC, Seizures May have onset after exertion or intense emotional activity More often during routine activity May occur during trauma

16 25% pts deterioration in the level of consciousness within the first 24 hrs Expansion of the hematoma : first 3 hrs Worsening cerebral edema : 24 ~ 48 hrs Late progression of edema: 2 ~ 3 weeks

anticoagulants (5) Location of bleed Broderick et al: mortality

17 Mortality rate : 23% ~ 58% in 6 months (1)GCS score on admission (2)Hematoma volume & its progression (3)Presence of IVH (4) Use of anticoagulants (5) Location of bleed Broderick et al: mortality rate at 1 month GCS < 9, volume > 60 ml 90% GCS 9, volume < 30 ml 17%

18 Hemphill et al. Stroke 2001, 32:891-97

19 CT Superior to MRI in acutely ill / stuporous pt. IVH CECT AVM/Aneurysm/Tumor CT Angio MRI Superior in detecting underlying structural lesions ( AVM etc. ) Gradient Echo MRI -as accurate as CT for identification of acute hemorrhage & more accurate for identification of Chronic hemorrhage

20 SAH Abnormal calcification Obvious vascular malformation Blood in unusual location, such as sylvian fissure No obvious cause of bleeding such as isolated IVH Zhu XL, Chan MS, Poon WS. Spontaneous intracranial haemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke. 1997;28:

21 Potential treatments of ICH Stopping or slowing the initial bleeding; Removing blood from the parenchyma or ventricles; Management of complications of blood in the brain, including increased ICP and decreased CPP Good clinical practice: Management of airways, oxygenation, circulation, glucose level, fever, nutrition, and DVT prevention. Lack of definitive randomized trials of either medical or surgical therapies for ICH, great variability in care

22 McKissocket al Primary Intracerebralhaematoma: a controlled trial of surgical and conservative treatment in 180 unselected cases Lancet 1961; ii: AuerLM et al Endoscopic surgery versus medical treatment for spontaneous intracerebral haematoma. A randomized study J Neurosurg 1989; 70: Batjer Hhet al Failure of surgery to improve outcome in hypertensive putaminal haemorrhage. A prospective randomised trial. Arch Neurol 1990; 47: JuvelaS et al The treatment of spontaneous intracerebralhaemorrhage. A prospective randomised trial of surgical and conservative treatment. J Neurosurg 1989; 70: Chen X et al A prospective randomisedtrial of surgical and conservative treatment of hypertensive intracerebral haemorrhage. Acta Acad Shanghai Med. 1992; 19: MorgensternLB et al Surgical treatment for intracerebralhemorrhage(stich). A single-center, randomised clinical trial. Neurology 1998; 51:

23 ZuccarelloM et al Early surgical treatment for intracerebralhemorrage. A randomized feasibility study. Stroke 1999; 30(9): Cheng X-C et al. The randomisedmulticentricprospective controlled trial in the standard treatment of hypertensive intracerebralhematomas: the comparison of surgical therapeutic outcomes with conservative therapy. Chin JClin Neurosci 2001; 9: HosseiniH et al Stereotactic aspiration of deep intracerebralhaematomasunder computed tomographic control, a multicentric prospective randomised trial. Cerebrovasc Dis 2003;16S4:57. Hattori N et al Impact of Stereotactic evacuation on activities of daily living during the chronic period following spontaneous Putaminal hemorrhage: a randomized study. J Neurosurg 2004; 101: Teernstra et al Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke 2003; 34: MendelowAD et al Early surgery versus initial conservative treatment in patients with spontaneous supratentorialintracerebralhaematomasin the International Surgical Trial in Intracerebral Haemorrhage(STICH): a randomised trial. Lancet 2005; 365:

24 Comparison of surgery plus medical vs medical treatment for outcome: death or dependence at end of follow-up Prasad K, ShrivastavaA. Surgery for primary supratentorialintracerebral haemorrhage(cochrane Review) In: TheCochrane Library Issue 4,2000. Surgery wasassociated with statistically significant reduction in the oddsof being dead or dependent at final follow up. Prasad, K. et al. Stroke 2009;40:e624-e626

26 International surgical trial in ICH (STICH) with 1,033 patients showed no difference in outcome, but some potential benefit in subgroup with lobar ICH ISTICH-IIwill include only lobar ICH with a subset analysis of those treated with rfviia Mendelow AD, et al. for the STICH Investigators. Lancet. 2005;365:

27 centers in 27 countries 1033 pts 503 early surgery and 530 initial conservative t/t

28 Results Favorable outcome at 6 months 122 (26%) with surgery 118 (24%) with initial conservative t/t (p=0.414) Mortality 36% vs. 37% Conclusion No overall benefit from early surgery compared with initial conservative treatment

29 Early surgery Initial conservative t/t GCS (20%) 106 (20%) (40%) 211 (40%) (41%) 213 (40%) Site Lobar 196 (39%) 214 (40%) BG/Thalamic 210 (42%) 224 (42%) Both 94 (19%) 90 (17%)

30 Early surgery Initial conservative t/t Volume (ml) 40 (24-63) 37 (23-60) Surgery 465 (94%) 140 (26%) Craniotomy 346 (75%) 119 (85%) Stereotaxy 34 (7 %) 3 (2 %) Endoscopy 31 (7 %) 7 (5 %) Other 54 (11%) 11 (8 %)

31 The STICH results do not significantly change current practice. Patients with a subcorticalor cerebellar hematoma at least 3 cm and impaired consciousness should be operated on. Comatose patients (GCS 8) with ICH in the basal ganglia or thalamus very unlikely benefit from clot removal. Minimally invasive methods may be useful if done early after ICH onset, but control of hemostasis may be difficult.

32 To establish whether earlier surgical evacuation of lobar ICH will improve outcome compared initial conservative treatment. To better define the indications for early surgery. This will overcome two of the criticisms of STICH (timing was too late and sometimes location was too deep).

33 Inclusion: Spontaneous lobar ICH on CT Scan Patient randomised within 48 hours of ictus Surgeon is in equipoise Best EYE score of 2 or more & M5/M6 Volume of haematoma ml

34 Exclusion: Aneurysm, tumour, trauma, angiographically proven AVM. Brain stem / cerebellar haemorrhage. Intraventricular haemorrhage, Hydrocephalus. Surgery cannot be performed within 12 hours. Unreversed clotting or coagulation problems. Severe pre-existing physical or mental disability or severe comorbidity

35 Patient randomized within 48 hours of ictus. If randomized to early surgery this should be undertaken within 12 hours. CT scan at about five days (+/-2 days). 600 patients will be recruited 30 months. FU will take 6 months with analysis and reporting taking 1 year. Outcome will be measured at 6 months via a postal questionnaire incl. the GOS, MRS, EuroQoland Barthel.

36 Many techniques Ultrasonic aspiration High pressure fluid irrigation Endoscopic aspiration Modified nucleotome Catheter aspiration with injection of thrombolytic agent (UK or tpa)

37 Potential advantages Deep putaminal or thalamic haemorrhages may be accessible Less damage to overlying brain 77% reduction in ICH volume at 48 hours, with no bleeding -Saline irrigation and aspiration after 1 mg rtpa q8h Vespa P, et al. Neurocritical Care. 2005;2:274.

38 Emergency diagnosis and assessment of ICH and its causes Rapid neuroimagingwith CT or MRI is recommended to distinguish ischemic stroke from ICH. Class I, Level A Medical treatment for ICH Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively. Class I, Level C

39 Hemostasis/antiplatelets/DV T prophylaxis Patients with ICH whose INR is elevated due to OAC should have their warfarinwithheld, receive therapy to replace vitamin K dependent factors and correct the INR, and receive intravenous vitamin K. Class I, Level C Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolismin addition to elastic stockings. Class I, Level B

40 Inpatient management and prevention of secondary brain injury General monitoring Initial monitoring and management of ICH patients should take place in an intensive care unit, preferably one with physician and nursing neuroscience intensive care expertise. Class I, Level B

41 Management of glucose Seizures and antiepileptic drugs Glucose should be monitored and normoglycemiais recommended Patients with clinical seizures should be treated with antiepileptic drugs. Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs Class I, Level C Class I, Level A Class I, Level C

42 Procedures/surgery clot removal Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. Class I, Level B

43 Prevention of recurrent ICH After the acute ICH, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy. Class I, Level A

44 (Class II a; Level of Evidence: B). CT angiography, CT venography, contrastenhanced CT, CEMRI, MRA& MRV can be useful to evaluate for underlying structural lesionswhen there is clinical or radiological suspicion (Class II b; Level of Evidence: B) CT angiography and contrastenhanced CT may be considered to help identify patients at risk for hematoma expansion

45 (Class IIa; Level of Evidence: B) PCCs have not shownimproved outcome comparedwith FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP (Class IIb; Level of Evidence: B) The usefulness of platelet transfusionsin ICH patients witha history of antiplatelet use is unclear and is considered investigational After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may beconsidered for prevention of venous thromboembolismin patientswith lack of mobility after 1 to 4 days from onset

46 (Class III; Level of Evidence: A) rfviiadoes not replaceall clottingfactors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rfviia is not routinely recommendedas a sole agent for OAC reversal in ICH Although rfviiacan limit the extent of hematoma expansionin noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rfviiaand no clear clinical benefit in unselectedpatients.thus rfviiais not recommended in unselected patients

47 In patients presenting witha systolic BP of 150 to 220 mmhg, acute lowering of systolicbp to 140 mm Hg is probably safe(class IIa; Level of Evidence:B). (New recommendation) If SBP is 200 mm Hg or MAP is 150 mm Hg Aggressive reduction and frequent monitoring (5 minutes) If SBP is 180 mm Hg or MAP is 130 mm Hg with elevated ICP Monitoring ICP Reducing BP to keep CPP >60 mm Hg If SBP is 180 mm Hg or MAP is 130 mm Hg no ICP issues, Modest reduction of BP (~MAP of 110/BP 160/90) Using intermittent or continuous IV meds Evaluate every 15 minutes.

48 (Class II a; Level of Evidence: B) Continuous EEG monitoring is probably indicated inich patients with depressed mental status out of proportion to the degree of brain injury (Class III; Level of Evidence: B) Prophylactic anticonvulsant medication should not be used

49 (Class II a;level of Evidence: B) Ventricular drainage as treatment for hydrocephalus isreasonablein patients with decreased level of consciousness (Class IIb; Level of Evidence: B) Although intraventricular administration of rtpain IVH appears to have a fairly low complicationrate, efficacy and safety of this treatment is uncertain andis considered investigational (Class II b; Level of Evidence: C) Patients with a GCS score of 8, those with clinical evidenceof transtentorialherniation, or those with significant IVHor hydrocephalus might be considered for ICP monitoring andtreatment.

50 (Class IIb; Level of Evidence: B) (Class IIb; Level of Evidence: C) For patients presentingwith lobar clots >30 mland within1 cm of the surface, evacuationof supratentorial ICH by standard craniotomy might be considered The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational For most patients with ICH, the usefulness of surgery isuncertain. Specific exceptions to this recommendation have been described.

51 (Class III; Level of Evidence: B) (Class III; Level of Evidence: C) Although theoretically attractive, no clear evidence atpresentindicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomymay be harmful due to increased risk of recurrentbleeding Initial treatmentof these patients with ventricular drainage alone rather than surgical evacuation is not recommended

52 (Class IIa; Level of Evidence: B) Aggressive full care early after ICH onset and postponementof new DNR orders until at least the second full day of hospitalizationis probably recommended

53 (Class II a; Level of Evidence:B) Risk factors for recurrence: lobarlocation of the initial ICH, older age, ongoing anticoagulation,presence of the apolipoproteine 2 or 4 alleles, and greater number of microbleedson MRI Afterthe acute ICH period, a goal target of a normal BPof <140/90(<130/80 if diabetes or chronic kidney disease) is reasonable Avoidance of long-term anticoagulation as treatment for nonvalvularatrialfibrillation is probably recommended after spontaneouslobar ICH because of the relatively high risk of recurrence

54 (Class IIa; Level of Evidence: B) Avoidance of heavy alcohol use can be beneficial (Class IIb; Level of Evidence:B) Anticoagulation after nonlobarich and antiplatelettherapy after all ICH might be considered, particularly when there are definite indications for these agents (Class IIb; Level of Evidence:C) There is insufficient datato recommendrestrictions on use of statinagents or physical or sexual activity

SCCEP 2013 LLSA Course Article 10 AHA/ASA Guidelines for the Management of Spontaneous ICH

SCCEP 2013 LLSA Course Article 10 AHA/ASA Guidelines for the Management of Spontaneous ICH Morgenstern LB, Hemphill JC. Stroke July 2010;41:2108-2129. Article: This article presents guidelines whose "aim