Jan 5, Coma 8 years. Jan 11, 2014

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1 Jan 5, 2006 Coma 8 years Jan 11, 2014

2 CT Scan of Head showing large right frontal ICH

3 The Intracerebral Hemorrhage: Team Approach Rodney Leacock MD

4 Introduction Intracerebral hemorrhage (ICH) is a very common health care problem with high mortality and morbidity It occurs as a result of blood extravasation into the brain primary and secondary causes are described

5 Primary Causes Spontaneous intracerebral hemorrhage due to hypertension Amyloid Angiopathy

6 Secondary Causes Trauma AVM Intracranial aneurysms Coagulopathy Hemorrhagic transformation of ischemic infarct Dural sinus thrombosis Intracranial neoplasm Cavernous angioma Dural AV fistula Venous angioma Cocaine or sympathomimetic drug exposure CNS vasculitis

7 Introduction Focus on primary ICH 37, ,000 events yearly Incidence per 100,000 More common in elderly Higher incidence in Asian and African Americans Mayer and Rincon. Lancet Neurology 2005 Broderick et al. Stroke. 1999, 2007,Morgenetern et al. Stroke 2010

8 Prognosis Mortality as high as 35% - 52% in 1 month 1 year mortality approaches 50% Half occur within 48 hours of presentation Serious cause of disability and morbidity Only 20% of patients regain functional independence at 6 months Broderick et al. Stroke. 1999, 2007, Hemphill et al. Stroke Mayer and Rincon. Lancet Neurology 2005

9 Risk Factor(s) Hypertension % of ICH Affects small penetrating arteries/arterioles micrometers in diameter Induces degenerative changes resulting in fragmentation and fibrinoid necrosis Microaneuryms Charcot Bouchard

10 Amyloid Angiopathy 15% of all primary ICH Deposition of amyloid beta in small and medium sized vessels Present with lobar ICH in elderly May be asymptomatic Can recur Associated with history of cognitive decline

11 Risk Factor(s) Heavy alcohol consumption Hypocholesterolemia Tobacco use is less well associated

12 Putamen 35% - 50% Lobar (Subcortical White Matter) 30% Thalamus 10% - 15% Pontine 5% - 12% Cerebellum 5% - 10% Location

13 Clinical Manifestations Putamen Sudden hemiparesis Sudden hemisensory loss Headache Impaired consciousness with expanding lesion Nausea Vomiting Lobar Speech impairment Asymptomatic Headache Hemiparesis Hemisensory impairment Visual impairment Impaired consciousness with expanding lesions

14 Clinical Manifestations Thalamus Hemisensory loss Hemiparesis Visual loss Diplopia Speech Impairment headache Impaired consciousness with expanding lesion Pontine Hemiparesis quadriparesis Facial asymmetry headache Impaired consciousness with destruction of RAS Gaze paresis Small pupils

15 Clinical Manifestations Cerebellum Headache Gait instability Nystagmus Appendicular ataxia Gaze palsy Facial palsy Vomiting Obtundation/ coma

16 Imaging Modalities CT head (I.A) Most readily available MRI Brain (I.A) MRA (IIa.B) CTA (IIb or IIa.B) Cerebral Angiography (IIa.B)

17 CT head showing large left parietal ICH

18 Brain MRI showing ICH T1 T2

19 Brain MRI showing ICH

21 Clinical Assessment Baseline Assessment (I.B) NIHSSS 0 42 Modified Rankin Score 0 6 Barthel Index ICH Score 1-6

22 Hemphill et al Stroke 2001 ICH Score

23 Pathophysiology

24 Hematoma Growth Early hematoma growth was reported by Brott et al. 38 % of patients showed hematoma growth within 3 hours of onset For intervals more than 6 hours growth was less prominent Multifactorial process including local and cascaded elements Mayer and Rincon. Lancet Neurology 2005

25 Perihematoma Injury Tissue damage and swelling Elevated ICP and mass effect No peri-hematoma ischemia Secondary neuronal injury and cytotoxic edema PET and MRI studies do not confirm tissue ischemia Mayer and Rincon. Lancet Neurology 2005

26 Perihematoma Injury Inflammatory process triggered by plasma rich in thrombin and other coagulation end products Activation and expression of cytotoxic and inflammatory mediators, induction of matrix metalloproteinases, leucocyte recruitment, and BBB breakdown Secondary tissue injury Mayer and Rincon. Lancet Neurology 2005

27 PATHOLOGY

28 Hypertensive ICH + IVH Ellison &Love: Neuropathology 2e, Elsevier Ltd 2004

29 Lobar ICH secondary to Cerebral Amyloid Angiopathy Ellison &Love: Neuropathology 2e, Elsevier Ltd 2004

30 Treatment Neuro-ICU or Specialized Stroke Unit I.B Dedicated physicians, advance practice providers, and nurses with neuroscience expertise Hemphill et al. Stroke. 2015

31 Hemphill et al. Stroke. 2015, Mayer and Rincon. Lancet Neurology 2005 Treatment Emergency Management Airway Breathing Circulation Airway/Breathing Intubate early if at aspiration risk or if going to OR PCO2 35 mm Hg Avoid ICP exacerbating agents

32 Treatment External ventricular drainage (IIa.B) Aka ventriclostomy for decreased LOC Intraventricular rtpa for IVH (IIb.B) Endoscopic removal for IVH (IIb.B) Hemphill et al. Stroke. 2015

33 Treatment Aggressive treatment within first three to six hours to limit hematoma growth For SBP Target SBP less or equal to 140 (I.A) CPP = MAP ICP Maintain CPP mm Hg (IIb.C) Mayer and Rincon. Lancet Neurology 2005 Broderick et al Stroke 2007, Hemphill et al. Stroke. 2015

34 Treatment: Blood Pressure Management Rose and Mayer, Neurocritical Care, 2004

35 Rose and Mayer, Neurocritical Care, 2004

36 Preferred Parenteral BP Agents drug mech dose labetalol -a1,-b1,-b mg, q10 min, max 300 mg,.5-2mg/min infusion esmolol -b1 500microg/kg bolus, microg/kg/min nicardipine L-type ccb 5 15mg/h infusion enalapril ACEI.625mg bolus, mg q 6h fenoldepam +DA mg/kg/min infusion nitroprusside vasodilator mg/kg/min infusion Rose and Mayer Neurocritical Care 2004; 1

37 Rose and Mayer Neurocritical Care 2004; 1 Preferred Parenteral BP Agents drug onset duration adverse effects labetalol 5-10min 3-6h Bradycardia, bronchospasm esmolol 1-2min 10-30min Bradycardia, hypotension nicardipine 5-10min 30min-4h Reflex tachycardia enalapril 15-30min 6-12h Variable response, cough fenoldepam 5-15min 30min-4h Tachycardia, ha nitroprusside immediate 1-4min n/v, thiocyanate toxicity

38 Antihypertensive treatment of acute cerebral hemorrhage Qureshi et al CCM 2010

39 Medical Complications Avoid hyperglycemia and hypoglycemia Fever control or temperature management Dysphagia screening Screen for myocardial ischemia DVT prophylaxis SCDs on admission (I.A) Hemphill et al. Stroke. 2015

40 Medical Complications DVT Prophylaxis Heparin or lovenox can be administered once cessation of hematoma expansion is documented (days 1 4) (IIb.B) DVT/PE Treatment (IIa.B) Systemic anticoagulation Timing will be the main issue IVC filter placement Hemphill et al. Stroke. 2015

41 Steroids Lack of evidence to support use in ICH Possible adverse effects III.B Hemphill et al. Stroke. 2015

42 Surgery Class IB evidence supports evacuation of cerebellar hematoma > 3 cm with worsening neurological status, brain stem compression, or hydrocephalus EVD insertion rather than surgical evacuation is not recommended as initial therapy (III.C) Broderick et al Stroke 2007; Hemphill et al. Stroke. 2015

43 Surgery In most patients with supratentorial ICH usefulness of surgery is not well established (IIb.A) Supratentorial ICH evacuation in deteriorating patients might be considered as life saving (IIb.C) Hemphill et al. Stroke. 2015

44 Surgery Decompressive craniectomy with or without hematoma evacuation might reduce mortality for patients who are in a coma, or have large hematomas with significant midline shift or elevated ICP (IIb.C) Hemphill et al. Stroke. 2015

45 Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage N = 12; 11 patients survived; hematoma volume > 60 cc in 8. Murthy et al. Neurocritical Care 2005

46 Surgery The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic removal with or without thrombolysis is uncertain (IIb.B) Hemphill et al. Stroke. 2015

47 3D CT guided multitract aspiration of BG ICH 4-5 drains were placed in BG and ventricular blood Urokinase 5000 IU irrigations every 2-3 hours Kim et al. Surgical Neurology 2005

48 Barrett et al. Neurocritical Care 2005

49 Surgery Adeoye et al. Neurosurgery 2008 Trends in surgical management and outcomes 1988 vs 2005

50 Coagulopathies and ICH Prothromin complex concentrate (IIb.B) rfvii (III.C) FFP (I.C) Vitamin K (I.C) Protamine (IIb.C) Platelets (IIb) Cryoprecipitate Broderick et al Stroke 2007; Hemphill et al. Stroke. 2015

51 Coagulopathies and ICH Dabigatran, rivaroxaban, apixaban related ICH FEIBA Other PCCs Or rfvii Activated charcoal Hemodialysis Hemphill et al. Stroke. 2015

52 Outcome Prediction and Withdraw of Technical Support Aggressive care early and postponement of new DNAR orders until at least the second full day of hospitalization (IIa.B) Patients with pre-existing are not included in this recommendation DNAR status should not limit appropriate medical or surgical interventions unless explicitly specified (III.C) Hemphill et al. Stroke. 2015

53 Recurrent ICH Prevention Stratification for ICH recurrence (IIa.B) Lobar location Age Microbleeds on MRI Anticoagulation Presence of apolipoprotein E e2 or e4 alleles Hemphill et al. Stroke. 2015

54 Recurrent ICH Prevention Immediate blood pressure control (I.A) Long term BP goal less 130/80 (IIa.B) Lifestyle modifications (IIa.B) Avoid or limit alcohol use less than 2 drinks/day Avoid tobacco or recreational drug use Treat obstructive sleep apnea

55 Recurrent ICH Prevention Avoid long term anticoagulation with warfarin after warfarin associated ICH for atrial fibrillation (non-valvular) due high risk of recurrence (IIa.B)

56 Recurrent ICH Prevention Anticoagulation for non lobar ICH and antiplatelet monotherapy may considered after ICH if there are strong indications (IIb.B)

57 Recurrent ICH Prevention Optimal timing to resume oral anticoagulation after warfarin related ICH is uncertain Avoidance of oral anticoagulation in patients without mechanical heart valves for at least 4 weeks might reduce the risk of recurrent ICH (IIb.B) If indicated aspirin therapy can started within days after ICH timing remains uncertain (IIa.B)

58 Recurrent ICH Prevention The usefulness of dabigatran, rivaroxaban, or apixaban in patients with atrial fibrillation and past ICH to reduce the risk of recurrence is uncertain (IIb.C) Insufficient data to restrict use of statin therapy in patients with ICH (IIb.C)

59 Rehabilitation and Recovery All patients with ICH should have access to multidisciplinary rehabilitation (I.A) Early rehabilitation should be initiated in the hospital and continued when back home in the community to promote on going recovery (IIa.B) Hemphill et al. Stroke. 2015

60 Conclusion Given the high mortality and morbidity prevention and risk factor reduction will be the key Surgical intervention: case by case assessment More randomized trials required More outcome studies and reporting to drive goal directed care Requires interdisciplinary care and participation

61 MLB Hall of Fame: Kirby Puckett Suffers massive stroke (ICH) and dies March 6, 2006

Stroke - Intracranial hemorrhage. Dr. Amitesh Aggarwal Associate Professor Department of Medicine

Stroke - Intracranial hemorrhage Dr. Amitesh Aggarwal Associate Professor Department of Medicine Etiology and pathogenesis ICH accounts for ~10% of all strokes 30 day mortality - 35 45% Incidence rates