Intracerebral hemorrhage
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Intracerebral Hemorrhage. Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL. Marc Dorfman, MD, FACEP, MACP. Case Presentation. 70 year old male Sudden onset, severe headache Took ASA for relief Collapsed Decreasing Mental Status.

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Intracerebral Hemorrhage

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Intracerebral Hemorrhage


Marc Dorfman, MD, FACEP, MACPEM Residency Program DirectorResurrection Medical CenterChicago, IL

Marc Dorfman, MD, FACEP, MACP


Case Presentation

  • 70 year old male

  • Sudden onset, severe headache

  • Took ASA for relief

  • Collapsed

  • Decreasing Mental Status


Physical Exam

  • T-98.6 P-61 BP-201/96 RR-16

  • Pupils-equal, sluggish, reactive

  • CV-NSR, no murmur

  • Skin-Bruise and flank from fall


More History

  • Long standing Hypertension

  • Unclear how well it was controlled

  • Postive-Tobbaco/Alcohol


Neurological Exam

  • Neurological exam:

    • no gag reflex, withdraws to pain, +4 DTR


GCS

  • Eyes-0

  • Verbal-0

  • Motor-4


NIH Stroke Scale

NIH Stroke Scale


NIHSS Score

  • Stroke scale 38


Key Clinical Questions

  • What is the epidemiology of ICH?

  • What are the most common etiologies ICH?

  • What is the pathophysiology of ICH?

  • How does ICH present?

  • Do patients with ICH present different than Ischemic stroke patients?

  • Does hemorrhage volume and GCS predict outcome?


Key Clinical Questions

  • How does hemorrhage volume increase over time?

  • What is the expected outcome of a patient with ICH?


Mission Statement

  • ICH is a cause of significant mortality and morbidity. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical and medical managements of patients with ICH. No consistently efficacious strategies have been identified in such investigations. Management of ICH unfortunately remains heterogeneous across institutions, and continues to suffer from the lack of proven medical and surgical effectiveness.

  • THIS IS CHANGING

Update on management of intracerebral hemorrhage; Neurosurgery Focus 15; 2003 1-6


Algorithm

Qureshi A, Tuhrim S: Spontaneous Intracerebral Hemorrhage; NEJM, Vol 344, No 19 May 10, 2001; 1450-1460


Intracranial Hemorrhage

  • Epidemiology

  • Etiology

  • Pathophysiology


Intracerebral Hemorrhage

2/3

Subarachnoid Hemorrhage

1/3

Stroke Epidemiology

Stroke

Hemorrhagic Stroke

15-20%

Ischemic Stroke

80-85%

Adapted from Scott PA, Barsan WG. Stroke, transient ischemic attack, and other central focal conditions.In: Tintinalli J. Emergency Medicine: A Comprehensive Study Guide. 5th ed. McGraw-Hill; 2000:1430.


ICH-Epidemiology

  • 10-15% of all strokes (80% ischemic)

  • More common in men than woman

  • More common after 55 years of age

  • Increased incidence in African Americans, Japanese, and Hispanic populations

Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005


ICH Epidemiology

  • 30 day mortality: 35-52%

    • 50% of these in first 48 hours

  • 10% independent at 1 month

  • One-fifth of survivors are independent at 6 months

  • 7000 operations annually in USA to remove blood

Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 199;30: 905-915


ICH Epidemiology-30 Day Mortality

  • Men 48%

  • Woman 41%

  • African American 42%

  • Lobar 39%

  • Deep 45%

  • Pontine 44%

  • Cerebellar 64%

Broderick: Volume of ICH; Stroke Vol 24, No 7


Etiology

  • Primary ICH (78-88% cases)-spontaneous rupture of small vessels damaged by

    • Hypertension (basal ganglia, thalamus, pons, cerebellum)

    • Cerebral Amyloid Angiopathy


Etiology

  • Pre-morbid Hypertension increases risk by 3.9%

  • Improved control of hypertension appears to reduce the incidence if intracerebral hemorrhage


Hypertensive ICH

  • Hypertension

    • Essential

    • Eclampsia

    • Sympathomimetics

      • Cocaine

      • Amphetamines

      • Phenylpropanolamine


Etiology

  • Cerebral Amyloid Angiopathy-50% individuals greater than 80 years old


Etiology

  • Low serum cholesterol (<160 reason unknown)

  • Alcohol consumption

  • Previous ICH-especially lobar hemorrhage


ICH Etiologies

  • Trauma

  • Vascular malformation

    • Aneurysm

    • Avm

    • Cavernous hemangiomas

  • Tumor

  • Coagulopathy

  • Vasculitis


Pathophysiology

  • Primary-immediate effects

    • Hemorrhage growth

    • Increased ICP

  • Secondary effects

    • Downstream effects

    • Edema

    • Ischemia

Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005


ICH Hemorrhage Growth

  • Several studies describe patients who had an increase in the volume of parenchymal hemorrhage on repeat CT scans


ICH Hemorrhage Volume

  • Old concept-Hemorrhage static process; bleeding complete in a minutes

  • New concept-Hemorrhage is dynamic; process continues for several hours


ICH Volume Growth


ICH Growth Study Design

  • 103 patients

  • CT scan baseline 1 and 20 hours

  • Positive-increase hemorrhage 33%

  • 38% patients with > 33% growth in volume of parenchymal hemorrhage


ICH Volume Growth

Comparison of variables between Baseline and 1 hour CTs


ICH Growth Study Conclusion

  • Substantial early hemorrhage growth in patients with with intracerebral hemorrhage is common and is associated with neurological deterioration.

  • Randomized treatment trials are needed to determine whether this ongoing bleeding and frequent neurological deterioration can be improved


ICH Hemorrhage Growth

  • Hematoma growth occurs in patients with normal coagulation profiles

  • Hematoma enlargement is associated with a worse outcome

  • Hematoma growth occurs within the first few hours (up to 40% in the first 3 hours) and is rare after 24 hours

Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005


Hemorrhage Growth-Predictors

  • Initial Hematoma volume

  • Early Presentation

  • Irregular shape

  • Liver disease

  • Hypertension

  • Hyperglycemia

  • Alcohol use

  • Hypofibrinogenima

Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005


Hemorrhage Volume-Mortality

  • Volume graters 60 cm3

    • Deep-93%

    • Lobar-71%

  • Volumes 30-60 cm 3

    • Deep-60%

    • Lobar-60%

    • Cerebellar-75%

  • Volumes less 30 cm

    • Deep-23%

    • Lobar-7%

    • Cerebellar-57%

Broderick: Volume of ICH; Stroke Vol 24, No 7


Hemorrhage Volume

  • Quick and dirty method

  • ABC/2

    • A-greatest hemorrhage diameter by CT

    • B-diameter 90 degrees to A

    • C-approximate number of CT slices with hemorrhage multiplied by slick thickness in cm

L Schwamm; Guidelines for Emergency Department Management of Brain Hemorrhage 2, 2004


Secondary Effects of ICH

  • Hematoma initiates edema

  • Edema is from osmotically active proteins from the clot

  • Vasogenic and cytotoxic edema lead to disruption of blood brain barrier and death to neurons

  • There may be unidentified secondary mediators of both neuronal injury and edema ( nuclear factor kappa-beta)

Qureshi A, Tuhrim S: Spontaneous Intracerebral Hemorrhage; NEJM, Vol 344, No 19 May 10, 2001; 1450-1460


ICH-Presentation

  • Basal ganglia (50%)

    • Contralateral hemiparesis, sensory loss, conjugate gaze

  • Lobar regions (20-50%)

    • Contralateral hemiparesis or sensory loss, aphasia, neglect, or confusion

  • Thalamus (10-15%)

    • Contralateral hemiparesis, sensory loss, gaze paresis

  • Pons (5-12%)

    • Quadriparesis, facial weakness, decreased level consciousness

  • Cerebellum (1-5%)

    • Ataxia, miosis, vertigo, gaze paresis

Acute Evaluation and Management of Intracerebral Hemorrhage; Stroke 1996


ICH Presentation

  • Hypertension (90%)

  • Altered mental status (50%)

  • Headache (40%)

  • Vomiting (49%)

  • Seizures (6-7%)


ICH-Hypertension

  • Risk factor for bleeding

  • May promote rebleeding (logical but unproven)

  • The big question-Will treating hypertension promote ischemia or how low can we go?


Altered Mental Status

  • Early decrease in level of consciousness seen about 50% patients

  • Uncommon finding in patients with ischemic stroke

Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30: 905-915


Headache

  • Occurs about 40% of patients

  • 17% with ischemic stroke

Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30: 905-915


Vomiting

  • 49% ICH

  • 2% Ischemic stroke

  • 45% with SAH

Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30: 905-915


Seizure

  • 28% of patients first 72 hours

    • Mostly lobar

  • Associated with Neurological worsening

  • Trend toward worse outcome

Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005


Presentation

  • Sudden onset of focal neurological deficit

  • Progresses over minutes to hours

  • Headache, N/V, Decreased LOC, Elevated BP

Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30: 905-915


ICH Diagnosis

CT scan is the most effective tool in the ED

  • CT scan

CT scan is excellent for imaging blood


Poor Outcome Risk Factors

  • Large or increasing volume of hematoma

  • Low GCS on admission

  • Interventricular clot extension and/or hydrocehalus

  • Anticoagulation agents

  • Relative edema

Update on management of intracerebral hemorrhage; Neurosurgery Focus 15; 2003 1-6


Poor Outcomes- Intraventricular Extension Hydrocephalus

  • Independent prognostic indicator

  • Important cause of neurological deterioration

  • Location importance?

  • Ventriculostomy-helpful?

Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005


Outcome predictor

  • Initial GCS

  • Initial hematoma volume

  • If GCS < 9 and hematoma volume > 60 ml mortality at one month 90%

  • GCS > 9 and hematoma volume < 30 ml mortality > 17%

Broderick, Brott; Volume if intracerebral hemorrhage: a powerful and easy-to-use predictor of 30 day mortality. Stroke 1993;24:987-93


ICH Score

  • UCSF

  • GCS (3-4(2) 5-12(1) 13-15(0)

  • ICH volume >30(1) <30(0)

  • IVH (yes, no)

  • Infratentorial origin of ICH (yes,no)

  • Age <80 yrs(0) or >80 yrs(1)

Hemphill III, Bonovich: The ICH Score;Stroke,April 2001 891-896


ICH Score

  • If score was six or greater all patients died

  • If score was zero all patients lived

Hemphill III, Bonovich: The ICH Score;Stroke,April 2001 891-896


ED Patient Management

  • Patient intubated in the ED

  • Stared on Nicardapine

  • BP-160/84 P-92 RR-Vented

  • Eyes-Pupils fixed

  • Patient expired within two hours of arrival


Key Learning Points

  • ICH makes up only 10-15% strokes

  • ICH occurs in hypertensives greater then 55 yrs of age

  • ICH presents differently than ischemic stroke

  • ICH volume expands over time-this is a marker for poor outcome

  • One can risk stratify poor outcomes based on simple numbers such as GCS, hemorrhage volume


[email protected] Dorfman, [email protected] 792 7921

dorfman_ich_aaem_2005 2/12/2005 7:48 PM

Marc Dorfman, MD, FACEP, MACP


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