New Frontiers in Intracerebral Hemorrhage

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Ross Stewart
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1 New Frontiers in Intracerebral Hemorrhage Ryan Hakimi, DO, MS Director, Neuro ICU Director, Inpatient Neurology Services Greenville Health System Clinical Associate Professor Department of Medicine (Neurology) The University of South Carolina-Greenville October 29, 2016

2 Disclosures Paid consultant, Arbor Pharmaceuticals Slides with an Association logo are courtesy of the National Stroke Images and figures from Continuum are from my own publication (Hakimi, R and Garg, A. Imaging of Hemorrhagic Stroke. Continuum, 2016.) Videos of clot evacuation devices are for informational purposes and do not serve as endorsement for such products

3 Objectives Describe the epidemiology of acute intracranial hemorrhages (ICH) Explain the importance of rapid evaluation and management of acute intracranial hemorrhages using neuroimaging modalities Discuss strategies for detecting and minimizing hematoma expansion

5 Types of Intracranial Hemorrhage

6 High Mortality of ICH

7 Epidemiology Of ICH Hemorrhagic stroke comprises approximately 15% to 20% Only 20% of survivors achieving full functional independence at 6 months

8 Initial Management of ICH Initial management Identification Determination of the underlying etiology Prevention of hematoma expansion Treatment of acute complications such as mass effect and obstructive hydrocephalus Treatment of the underlying etiology, if indicated.

9 Identification of ICH Head CT without contrast is the first diagnostic modality used when a patient presents with neurological dysfunction Widely available Lower cost than MRI High sensitivity for blood in the first week post-ich Feasibility in imaging unstable patients Head CT allows for identification of: Intraventricular extension Extent of cerebral edema Extent of mass effect Estimation of blood volume

10 Sites of Spontaneous ICH

11 Calculating the ICH Volume

12 Calculating the ICH Score

13 Prognostication Using the ICH Score

14 Evaluation of ICH 1/3 with hemorrhagic stroke will have hematoma expansion on follow-up head CT within the first 3 hours of symptom onset Presence of a spot sign on head CT angiography is indicative of active hemorrhage and predictive of hematoma growth; it may favor admittance to the intensive care unit even if the patient is not intubated and appears to be clinically stable Hyperattenuation of acute blood on head CT is based on the protein content of whole blood (i.e., hemoglobin) Therefore, in patients with serum hemoglobin less than 10 g/dl, hyperattenuation may be limited, resulting in reduced ability to identify ICH

16 Role of MRI in ICH Modern 1.5T MRI machines are equally sensitive at identifying acute symptomatic ICH as CT MRI is more sensitive than CT at identifying subacute ICH Susceptibility-weighted imaging (SWI) which is a high-resolution three dimensional gradient recalled echo (GRE) MRI sequence, is most sensitive in detecting small amounts of hemorrhage MRI allows for distinction between the two most common etiologies of hemorrhagic stroke: Arterial hypertensive vasculopathy Cerebral amyloid angiopathy

17 Role of MRI in ICH Limitations associated with MRI, other than cost, center on logistic and patient-specific characteristics Logistic limitations: ability to obtain the study in a timely fashion Patient specific limitations Presence of a pacemaker or ferromagnetic foreign object Claustrophobia Large body habitus Inability to lie flat

18 MRI Challenges Throughput Studies ordered through the emergency department are typically ordered to be performed emergently Most centers cannot accommodate numerous emergent MRI studies Establishing a hospital protocol for obtaining MRI scans based on priority levels may be a very practical and efficient way to triage patients for MRI and may result in better use of limited resources

19 MRI Levels Protocol MRI Levels Protocol developed by Hakimi and colleagues at OU Medical Center Level 1: Indicated only when the findings of the study will determine whether the patient will need a surgical or endovascular intervention. The MRI is expected to be completed and reported within 90 minutes of order Level 2:Indicated only when the findings of the study will determine the patient s disposition, such as discharge to home, admit to floor, or admit to the intensive care unit. The MRI is expected to be completed and reported within 4 hours of order. Level 3:Indicated when the MRI will supplement the plan of care, such as in a patient with an acute ischemic stroke and low National Institutes of Health Stroke Scale score who is outside of the thrombolysis or interventional window. The MRI is expected to be completed and reported within 24 hours of order.

20 Blood Pressure Management Attach-II Trial (2016) Patients within 4.5 hours of ICH onset GCS over 5 Hematoma volume less than 60 cm 3 SBP 180 mmhg Randomly assigned to blood pressure reduction with intravenous nicardipine to achieve systolic pressures in the range of 140 to 179 mmhg (standard care) or 110 to 139 mmhg (intensive blood pressure lowering) In reality it was around less than 140 mm Hg in (standard group) and 110 mm Hg (intensive group) No significant benefit although less hematoma expansion but more adverse events

21 Interact-II Acute spontaneous ICH onset <6 hours SBP 150 and 220 mmhg No definite indications or contraindications to treatment Able to be actively managed Provide informed consent R Standard best practice stroke unit care Intensive BP lowering Target systolic BP 140 mmhg within 1 hour and for 24+ hrs Conservative BP management AHA Guideline-based (treatment if systolic BP >180 mmhg) Repeat CT scans 24 hrs in selected patients Vital signs and BP over 7 days 28 day and 3 month follow-up

22 Conclusions from INTERACT2 Primary endpoint MRS 3-6, better outcome in intensive treatment group (p=0.06) If endpoint were MRS 2-6, there would have been statistical significance (p=0.03) Demonstrated safety with intensive treatment as neurologic deterioration, expansion of the intracerebral hemorrhage, ischemic stroke, cardiovascular events, or severe symptomatic hypotension were equal

23 Putting it All Together My interpretation: Blood pressure target in acute ICH is less than 140 mm Hg

24 Surgical Intervention in ICH STICH Trial (Mendelow AD, Gregson BA, Fernandes HM, et al, for the STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005; 365: ) No statistically significant benefit from surgical evacuation of the clot Trend toward benefit from surgical evacuation when the clot was lobar and within 1 cm of the cortical surface

25 STICH II Trial (Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM, for the STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013; published online May 29.

26 Devices on the Horizon Brain Path (Nico Corporation) Apollo System (Penumbra Corporation)

Tyler Carson D.O., Vladamir Cortez D.O., Dan E. Miulli D.O.

Tyler Carson D.O., Vladamir Cortez D.O., Dan E. Miulli D.O. Bedside Intracranial Hematoma Evacuation and Intraparenchymal Drain Placement for Spontaneous Intracranial Hematoma Larger than 30 cc in Volume: Institutional Experience and Patient Outcomes Tyler Carson