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Intracranial Hemorrhage

Intracranial Hemorrhage. Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL. Marc Dorfman, MD, FACEP, MACP. Case Presentation. 57 year old female Sudden onset, severe headache Took ASA for relief Slurred speech Collapsed. Physical Exam.

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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

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