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Intracranial Hemorrhage
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  1. Intracranial Hemorrhage

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

  3. Case Presentation • 57 year old female • Sudden onset, severe headache • Took ASA for relief • Slurred speech • Collapsed

  4. Physical Exam • T 99.4 P52 BP 195/99 RR13 • Pupils-2 mm reactive • Neck-no JVD, bruits • CV-bradycardia, no murmur • Abd-bs+, soft , nt/nd • Skin-warm and dry

  5. Neurological Exam • Neurological exam: • no gag reflex, withdraws to pain, +4 DTR

  6. GCS • Eyes-1 • Verbal-1 • Motor-4

  7. NIH Stroke Scale NIH Stroke Scale

  8. NIHSS Score • Stroke scale 25

  9. CT Scan

  10. NY Times

  11. Key Clinical Questions • What are the most common etiologies and locations of ICH? • What are the goals of BP management? • What are the optimal strategies for managing ICP? • What other treatment modalities are available to the ED physcian?

  12. Key Clinical Questions • Which ICH patient require surgery? • How does hemorrhage volume change over time? • Does hemorrhage volume growth affect mortality? • What are the new therapies being tested for this disease process?

  13. Intracranial Hemorrhage • Epidemiology • Etiology • Diagnosis • Treatment • BP management • Neurosurgical indications • New treatment modalities

  14. ICH Epidemiology • 30 day mortality: 35-52% • 50% of these in first 48 hours • One-fifth of survivors are independent at 6 months • 7000 operations annually in USA to remove blood

  15. ICH Types • Epidural • Subdural • Subarachnoid • Intraparencymal • Intraventricular • Cerebellar

  16. Hypertensive ICH • Hypertension • Essential • Eclampsia • Sympathomimetics • Cocaine • Amphetamines • Phenylpropanolamine

  17. Hypertensive ICH • 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, gaze paresis

  18. Other ICH Etiologies • Amyloid • Trauma • Vascular malformation-Avm, cavernoushemangiomas • Aneurysm • Tumor • Coagulopathy • Vasculitis

  19. ICH Presentation • Hypertension (90%) • Altered mental status (50%) • Headache (40%) • Seizures (6-7%)

  20. ICH Diagnosis CT scan is the most effective tool in the ED • CT scan CT scan is excellent for imaging blood

  21. ICH Rx Key Concepts • Two key concepts: • Intracranial pressure • Elevated when ICP >20 mm Hg • Cerebral perfusion pressure • CPP=MAP-ICP • Must maintain ICP > 70 mm Hg • Example: MAP = 100, ICP = 20 • CPP in above example = 80 mmHg

  22. Increased ICP Treatment • Intracranial Pressure (ICP): considered a major contributor to mortality when elevated • Controlling ICP is considered essential • Osmotherapy • Hyperventilation • Barbiturate coma

  23. Clinical Case: ED Rx • Patient starts to vomit • B/P 266/122 • RSI • Lidocaine 100 mgs • Etomadate 20 mgs • SuccinylCholine 100 mgs • Mannitol 150 ccs • Elevate Head of Bed • Hyperventilation to pCO25-30

  24. Clinical Case: ED Rx • Paralytics-Pancuronium 7 mg • BP management-Nipride • Steroids-Decadron 10 mgs

  25. Osmotherapy • Osmotherapy-Mannitol • Reduces cerebral edema by decreasing cerebral fluid volume • Rebound effect-use less than 5 days • 20% solution • 0.5-1.0 mg/kg maintain serum osmolarity 310-320 mOsm/L

  26. HOB Elevation • Elevate head of bed-decrease ICP • Mechanical-helps drain blood by gravity • Does not allow blood to pool in cranium, which may occur if patient is left laying flat

  27. Endotracheal Intubation • Intubation-not required, but airway protection and adequate ventilation are necessary • Rely on clinical suspicion, not GCS • Hyperventilation decreases ICP • pCO2 should be kept around 30-35 • Beneficial effect of sustained hyperventilation is not proven

  28. Paralytics • Recommended in order to prevent increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT, all of which may cause ICP spikes • ICP spikes associated with poorer outcome, especially in setting of elevated ICP

  29. ICP Monitors • AHA recommends ICP monitors in patients with a GCS less than 9 and all patients whose condition is thought to be deteriorating due to elevated ICP

  30. BP Management • Lower blood pressure to decrease risk of ongoing bleeding from ruptured small arteries • Overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injury • Especially true with elevated ICP

  31. BP Management • AHA recommends blood pressure be maintained below a mean arterial pressure of 130 mm Hg in persons with a history of hypertension • If there is an ICP monitor: • ICP should be kept < 20 m Hg • Cerbral perfusion pressure (MAP-ICP) should be kept > 70 mm Hg

  32. BP Management • Avoid hypotension • If systolic BP drops to less than 90 mmHg, consider judicious fluid boluses and/or start pressors

  33. BP Management • Labetalol • 20 mg IV, followed by 40 80 mg IV q10 min • Titrate to BP or max 300 mgs admin • Nipride • 0.5-1.0 mics/kg/min • Theoretically can increase cerebral blood flow and thereby intracranial pressure

  34. BP Management • Treatment should be started within 6 hours of symptom onset • A Prospective Multicenter Study to Evaluate the Feasibility and Safety of Aggressive Antihypertensive Treatment in Patients with Acute Intracerebral Hemorrhage • Journal of Intensive Care Medicine, Vol 20, No 1 • Burke, Dorfman-not yet published

  35. Fever Management • Elevated temperatures can increase the degree of ischemic injury. • Etiologies include infection, neuronal injury, SIRS • Studies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation. • Treat temperture > 38.5˚ C • Acetaminophen or a cooling blanket best options.

  36. Seizure Therapy • Neuronal injury may lead to seizures • Nonconvulsive seizures may contribute to coma in up to 10% of neurocritical patients • Consider prophylactic antiepileptic therapy in setting of ICH • Lobar hemorrhage-35% seizure rate • Fosphenytoin or phenytoin

  37. Medical Therapy • Euvolemia • Isotonic crystalloid solutions • Electrolyte abnormalities • Correct deficits • Acid/base disorders • Correct them if present • Steroids-no benefit

  38. Blood Clot

  39. ICH Hemorrhage Growth • Until recently, bleeding in patients with ICH was thought to be completed within minutes of onset • Several small studies describe a few patients who had an increase in the volume of parenchymal hemorrhage on repeated CT scans

  40. ICH Hemorrhage Volume • Old concept-Hemorrhage static process; bleeding complete in a minutes • New concept-Hemorrhage is dynamic; process continues for several hours

  41. ICH Hemorrhage Growth • Early Hemorrhage Growth in Patients With Intracerbral Hemorrhage • Brott, Broderick, Kothari • Stroke Vol 28, 1 January 1998

  42. ICH Growth: Study Purpose • Prospectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to neurological deterioration

  43. ICH Growth Study Design • 102 patients • CT scan 3 hours and 24 hours • 38% patients with > 33% growth in volume of parenchymal hemorrhage

  44. ICH Growth: Conclusions • 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

  45. ICH Factor VIIa Study • Safety and Feasibility of Recombinant Factor VIIa for Acute Intracerebral Hemorrhage • Mayer, Nikolai, Brun • Stroke, Jan 2005, 36(1) p74-9

  46. ICH Factor VIIa Study Purpose • Factor VIIa-promotes clotting-know to do so in hemophiliacs • Activated factor VII promotes hemostasis at sites of vascualr injury and may minimize hematoma grwoth in ICH

  47. ICH Factor VIIa Study Design • 48 subjects • Randomized double blind placebo controlled • Escalating doses of factor VII • Endpoint-frequency of adverse events

  48. ICH Factor VIIa Study Conclusion • Phase II trial • No major safety concerns • Larger study needed to determine if factor VII can safely and effectively limit ICH growth

  49. ED Patient Management • Neurosurgery consulted • EVD placed in the ED • Patient taken to the OR for evacuation of hematoma • BP-119/79 P-92 RR-12

  50. Patient Outcome • Next day: brain flow studies • Patient declared brain dead • Patient extubated