Neurologic Emergency: Intracranial Hemorrhage Stabilization, and Effective Communication for the Non-Neurologist

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1 Neurologic Emergency: Intracranial Hemorrhage Stabilization, and Effective Communication for the Non-Neurologist Giuseppe Ciccotto MD, MPH Dept. of Neurosurgical Critical Care Ochsner Health System, New Orleans, Louisiana Associate Professor, University of Queensland, Australia Objectives Review Stroke and ICH/SAH statistics Review ENLS Golden Hour in ICH/SAH Discuss Effective Communication of ICH/SAH severity Learn BP management in ICH/SAH Learn Anticoagulant reversal in ICH/SAH 1

Stroke 5 th leading cause of death in the Unites States ~795,000 strokes per year ~140,000 deaths from stroke per year 1 stoke every 4 seconds 1 stroke death every 4

2 Stroke 5 th leading cause of death in the Unites States ~795,000 strokes per year ~140,000 deaths from stroke per year 1 stoke every 4 seconds 1 stroke death every 4 minutes Benjamin, E. J., et al. (2017). "Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association."Circulation 135(10): e146-e603. 2

3 (AHA 2016) stroke belt N. Carolina S. Carolina Tennessee Mississippi Alabama Louisiana Arkansas Howard G, Anderson R, Johnson NJ, Sorlie P, Russell G, Howard VJ.Evaluationof social status as a contributing factor to the stroke belt regionof the United States. Stroke. 1997;28: Intracranial Hemorrhage Spontaneous 10-20% SAH 3-7% 10-20% of all strokes 3-7% SAH Ischemic 80% Norrving, B. (2014). Oxford textbook of stroke and cerebrovascular disease. Oxford, United Kingdom ; New York, Oxford University Press.pg

4 Spontaneous Hemorrhage Overall incidence in United States Up to 67,000 cases/per year 30 day mortality of 35% -52% Up to 50% of mortality occurs in first 24 hours 20% or survivors have full functional recovery at 6 months Meaning 80% will have disability Caceres, J. A. and J. N. Goldstein (2012). "Intracranial hemorrhage." Emerg Med Clin North Am 30(3): AHA 2016 > 20% will decline by 2pt on GCS EMSER 15%-23% continued deterioration in first hours after arrival Symptoms non-specific (ICH vs AIS) Vomiting SBP > 220mmHg Abrupt onset Focal exam Imaging mandatory 4

5 Most Importantly 38% of cases exhibit significant [hematoma] growth, defined as > 33% volume increase, over first 24 hours with most occurring within first 3-4 hours BrottT, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997;28:1 5. ICH is a dynamic process where the treatment goal is limitation of stroke volume Mayer SA. Ultra-early hemostatic therapy for intracerebral hemorrhage. Stroke 2003;34: Spontaneous ICH Hypertension Vascular anomalies Aneurysms AVMS Cavernomas CAA Neoplasms EtOH/illicit drugs (cocaine, methamphetamines) OATs Other Norrving, B. (2014). Oxford textbook of stroke and cerebrovascular disease. Oxford, United Kingdom ; New York, Oxford University Press. 5

6 Subarachnoid Hemorrhage 6-8/100,000 population 10-15% of patients die before reaching hospital Overall mortality 32%-67% Etiology (non-traumatic): Aneurysm rupture: 75%-80% AVM: 4-5% Unknown/other: 15-22% Greenberg, M. S. and M. S. Greenberg (2010). Handbook of neurosurgery. Tampa, Fla. New York, N.Y., Greenberg Graphics ;Thieme Medical Publishers.pg1034 Aneurysmal SAH Etiologies: Congenital predisposition/family history Atherosclerosis/ chronic HTN/smoking Embolic Infectious other Greenberg, M. S. and M. S. Greenberg (2010). Handbook of neurosurgery. Tampa, Fla. New York, N.Y., Greenberg Graphics ;Thieme Medical Publishers.pg

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8 SAH S & S (AHA 2012) Worst headache of life ~80% Nausea/vomiting ~77% LOC ~53% Nuchal rigidity ~35% Seizure ~24% Sentinel headache ~10-43% (2-8 weeks prior) 8

9 Aneurysm Rupture (AHA 2012) More common in >7mm If HTN and Smoker <7mm Anterior location <55yo Significant life event within past month asah Rebleed(AHA 2012) Re-bleed associated with very high mortality Poor prognosis of functional recovery Peak 2-12 hours 4-13% with first 24 hours ~33% of re-bleeds in first 3 hours >50% of re-bleeds within first 6 hours 9

aneurysm obliteration Possibly SBP > 160mmHg Hypertensive ICH

10 Risk of Re-bleed (AHA 2012) Higher with worse HH,WFNS scales Loss of consciousness at onset Sentinel Headache Delay in aneurysm obliteration Possibly SBP > 160mmHg Hypertensive ICH 10

11 Case courtesy of A.ProfFrank Gaillard, Radiopaedia.org, rid: Case courtesy of Radswiki, Radiopaedia.org, rid: Case courtesy of Dr Farzad Pirzad, Radiopaedia.org, rid: 9620 Case courtesy of Radswiki, Radiopaedia.org, rid:

Cerebral Amyloid Angiopathy Case courtesy of

org, rid: 46082 Vascular Malformations (2018).

12 Cerebral Amyloid Angiopathy Case courtesy of RMH Neuropathology, Radiopaedia.org, rid: Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rid: Vascular Malformations (2018). "AVM." from 12

spine." from http://www.avmsurgeon.com/aboutavms.

13 (2018). "arteriovenous malformations of the brain and spine." from

14 The Golden Hour Prepare for what can go wrong (is going wrong) Herniation Airway Hematoma expansion Increasing ICP Seizures Fever Hyperglycemia 14

15 GCS, ICH score, HH, (m)f, WFNS BP management Anticoagulation Reversal 15

16 Case 1 83 yoaam, right handed PMHx HTN (amlodipine), and Afib(carvedilol, dabigatran), with sudden left sided weakness, right gaze, diaphoretic, inappropriate responses. INR 2.3 Protecting airway GCS (12) E3V3M6 BP: 198/103 mmhg Range from 3-15; Arbitrary GCS 8=Intubate 16

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18 13% 26% 72% 97% 100% 18

19 Calculate the ICH Volume Derived from volume of an ellipsoid Amaximal length B maximal Width C number of CT slices xslice thickness Originally 10-mm slices To nearest 0.5 CM on CT scale [A*B*C]/2= cm 3 (ml) Kothari, R. U., et al. (1996). "The ABCs of measuring intracerebral hemorrhage volumes." Stroke 27(8): [A*B*C]/2 A=47mm (4.7cm) B=39mm (3.9cm) C=# slices * thickness [4.7*3.9*(7*0.5)]/2 32.1mLor cm 3 C=7 slices Thickness 5 mm (.5cm) 19

20 ICH score: 3 GCS 12 Volume >30mL >80yo 72% 30day mortality 83yo M GCS 12, ICH score 3 (72% 30d mortality) BP: 198/103mmHg Anticoagulation: Dabigatran INR

Blood Pressure: ATACH (2010) & INTERACT (2010): rapid SBP lowering to <140mmHg safe INTERACT 2 (2015): Early lowering SBP < 140mmHg did not reduce risk of death or severe disability Better functional

21 Blood Pressure: ATACH (2010) & INTERACT (2010): rapid SBP lowering to <140mmHg safe INTERACT 2 (2015): Early lowering SBP < 140mmHg did not reduce risk of death or severe disability Better functional outcome with lower mrs ATACH II (2016): No difference in mortality and morbidity in mmHg versus mmHg (increase in renal adverse events in intensive arm) AHA Keep SBP 140mmHg to 180mmHg -<140mmHg safe but no benefit in mortality, may have better functional outcome 21

22 Medications IV Nicardipine Calcium channel blocker Titratable IV labetalol Pushes Alpha and beta blocker Hydralazine/Nitroprusside Venodilators Risk of increasing ICP 83 yom GCS 12, ICH score 3 (72% 30d mortality) BP: nicardipine gttgoal SBP <140mmHg ( mmHg) Anticoagulation: Dabigatran INR

23 NCS 2016 Vit-K Replenished substrate for Factors II, VII, IX, X Could take up to >24-48 hours to get INR < 1.4 Risk of anaphylaxis 3/10,000 FFP (Fresh Frozen Plasma) Provides all clotting Factors Could take 2-30 hours to get INR < 1.4 Long processing time; blood type matching, thawing, transfusion time Large volume needed: Pulmonary edema, TRALI, TACO PCC (Prothrombin Complex Concentrates) 3 and 4 factor (VII) (FEIBA, apcc) Plasma derived=no crossmatch needed Small volume, faster infusion can normalized INR mins Thrombosis risk Expensive Not available everywhere rfviia(recombinant activated Factor VII) INR PT correction comparable to PCC Could be falsely low Expensive Increased thrombosis 23

24 VK-A Reversal (NCS 2016) Vitamin K(strong, mod.) VitK10 mg IV, re-dose if INR >1.4 in hours Administer PCC over FFP if INR >1.4 (strong, mod.) FFP + Vit K over no treatment (strong,mod.) Heparin and LMWH Protamine based on Units and time from last dose Heparin 1mg:100 Units LMWH 1mg:1mg 24

http://n.neurology.org/content/78/7/501.

25 Antiplatelet agents COX-inhibitors ASA, NSAID ADP receptor inhibitors Clopidogrel, Prasugrel, Ticagrelor 25

26 NCS 2016: antiplatelet reversal No reversal for ICH not going to OR (cond., low) PLTs transfusion for ASA or ADP goingto OR (cond., mod) PLT function testing prior, no PLTs if resistant (strong, mod.) DDAVP (0.4mcg/kg IV) +/-PTLS in ASA or ADP going to OR (cond., low) Direct Factor Xa inhibitors Rivaroxaban Apixaban Edoxaban Direct Thrombin Inhibitors Dabigitran Argatroban 26

27 NCS 2015: direct Xa-I reversal Activated charcoal (50g) in intubated or low aspiration risk within 2 hours of ingestion (cond.,very low) 4 factor PCC (50U/kg) or apcc(50 U/kg) if within 3-5 terminal half lives, or liver failure (cond., low) 4PCC or apccover rviia(cond., low) NCS 2016: Dabigatran Idarucizumab(5g IV in two divided doses) If dabigatranwithin 3-5 half lives or renal insufficiency (strong, mod.) apcc(50u/kg) or 4PCC (50U/kg) If non-dabigatran(cond., low) If bleeding continues redoseidarucizumabor HD (cond., low) Recommend against FFP or rfviia(strong, low) 27

28 83 yom GCS 12, ICH score 3 (72% 30d mortality) BP: nicardipine gttgoal SBP <140mmHg ( mmHg) Anticoagulation: gave PCC 25U/kg for INR 2.3 Case 2: 43 yoright handed woman with PMHx smoking (20py), HTN (amlodipine, lisinopril), presents with sudden excruciating headache, lethargic, and left sided weakness. GCS: 8 E2V2M4 BP: 179/109mmHg Occasional aspirin 28

29 341-overview SAH Scales Hunt-Hess: 1967 Patient severity after TBI Risk of perioperative mortality World Federation of Neurosurgical Societies (WFNS): 1988 Death and disability (level of consciousness) GCS Morbidity (hemiparesis and aphasia) Focal deficit Fisher(F): 1980 Risk of vasospasm Requires imaging Modified Fisher (mf): 2001 Revised to account for cisternal and intraventricular hemorrhage 29

30 Hunt, W. E. and R. M. Hess (1968). "Surgical risk as related to time of intervention in the repair of intracranial aneurysms." J Neurosurg 28(1): Deficit: aphasia, hemiparesis, hemiplegia Teasdale GM, Drake CG, Hunt W, KassellN, Sano K, PertuisetB, De Villiers JC. A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry Nov;51(11):

31 Modified Fisher Simplified SAH thick/thin and IVH +/- Risk of Delayed Cerebral Ischemia (DCI) 31

Stroke 2001 43yo F GCS 8, HH3, WFNS IV, mf3

32 Stroke yo F GCS 8, HH3, WFNS IV, mf3 BP:179/109mmHg Anticoagulation: not an issue 32

33 AHA/ASA 2012 SBP should be controlled with titratable agent up-to time of obliteration to balance risk of stroke, HTN related rebleed, and maintain CPP (Class I, Level B) Magnitude of SBP control to reduce re-bleed risk has not been established, but goal <160mmHg is reasonable (Class IIa, Level C) 43yo F GCS 8, HH3, WFNS IV, mf3 BP: nicardipine for SBP goal < 140mmHg Anticoagulation: not an issue 33

34 Stabilization/Communication Golden Hour (ENLS) Everyone gets a GCS ICH/SAH: ICH score HH, WFNS (choose your favorite) SBP: ICH: mmHg, <140mmHg is safe SAH: <160mmHg Coagulation reversal (NCS 2016) Transfer to NSCCU Thank You 34

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Modern Management of ICH

Modern Management of ICH Bradley A. Gross, MD Assistant Professor, Dept of Neurosurgery, University of Pittsburgh October 2018 ICH Background Assessment & Diagnosis Medical Management Surgical Management