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Intracerebral Hemorrhage

Intracerebral Hemorrhage. McGill Lecture Series Montreal, QC September 19, 2012. J. Teitlelbaum, MD, FRCP(C) University of McGill. Case History G.S. 68 year old R HBP, DB2, CAD 5PM, sudden R paresis Aphasia Ø headache, N or V. G.S. Exam on arrival BP 190/100 P 75/min

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Intracerebral Hemorrhage

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  1. Intracerebral Hemorrhage McGill Lecture Series Montreal, QC September 19, 2012 J. Teitlelbaum, MD, FRCP(C) University of McGill

  2. Case History G.S. • 68 year old R • HBP, DB2, CAD • 5PM, sudden • R paresis • Aphasia • Ø headache, N or V

  3. G.S. • Exam on arrival • BP 190/100 P 75/min • Alert, aware, mixed moderate aphasia • CN: PERL, RHHA, R UMN VII, R ↓↓ sensation • 2/5 strength R UE & LE • ↓↓ sensation R hemi-body

  4. CT 5:30PM

  5. G.S. Sudden Deteriororation • Exam at 7PM • GCS 10, very somnolent, not obeying commands, groans & opens eyes to voice. • Pupils 4mm L 3mm R reactive • Poor airway protection • Power 0/5 R UE & LE

  6. CT at 7:05 PM

  7. G.S. Now what ?? • ICH • Epidemiology & Etiology: • primary vs secondary • Factors that affect prognosis • Management • Evidence-based • Eminence based • Experimental & anecdotal

  8. The Guidelines • Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: Circulation. 2007;116:e391–413.

  9. ICH Incidence in 2003

  10. Intracerebral Hemorrhage • 15% of stroke in the West, 30% in the East • 6 month prognosis dismal • 40% dead (33% within 1 month) • 40% disabled and dependent • 20% independent

  11. Classification of ICH PRIMARY (78-88%) Hypertensive angiopathy (fibrohyalinosis) Amyloid angiopathy Anticoagulant Associated SECONDARY AVM Aneurysm Cavernoma Neoplasm Coagulopathy Alcoholic liver disease Hemophilia Hemorrhagic infarct Toxic-cocaine

  12. Dismal Prognosis

  13. Factors Affecting Prognosis • GCS on presentation • Age • Hemorrhage location • Intraventricular hemorrhage • ? Blood pressure • Hemorrhage size

  14. Secondary Damage Hematoma expansion ≥ 80 ml fatal Cerebral edema Secondary injury

  15. ICH Score

  16. Mortality and ICH Score

  17. FULL RECOVERY DEAD The relationship between ICH volume and patient outcome

  18. Size is the most important predictor for patient outcome A patient with a haemorrhage the size of a ping pong ball is likely to have a better outcome than a patient with a haemorrhage the size of golf ball: • mortality on ’ping pong’ size: app. 40% • mortality on ’golf ball’ size: app. 70% 38 ml 43 ml

  19. Which are Modifiable ? GCS on presentation Age Hemorrhage location Intraventricular hemorrhage ? Blood pressure Hemorrhage volume

  20. Early growth occurs in all locations

  21. Hematoma Evolution 3 h 3 h 2 h 6 h 24 h 24 h

  22. Predicting ICH expansion Time since onset Spot sign Blood pressure Shape of the hematoma

  23. CTA Source Images: Additional Data Spot Sign

  24. The Spot Sign: Growth Despite Treatment 2 hours 3 hours (CT Angiogram) 24 hours rFVIIa

  25. Predictive Value of Spot Sign: Time Dependent? 3 hours 4.5 hours 24 hours Spot Sign

  26. Early Growth: Conventional angiography

  27. Prognosis and Acute Blood Pressure ↑ Early Neurological Deterioration ↓ Functional Outcome (90 days) 1 month mortality (%) 1 month mortality (%) MAP (mm Hg) Fogelhom et al, Stroke, 28: 1396-400, 1997 Okumura et al, J. Hypertension, 23: 1217-23, 2005

  28. Blood Pressure and Hematoma Evolution Ohwaki et al, Stroke, 35: 1353-1367, 2004

  29. ICH Management

  30. Treatment Modalities General supportive care Treatment of ICHT Hematoma resection Management of intra-ventricular hemorrhage Seizure prophylaxis Prevention of hematoma growth BP management

  31. Basic Algorithm • ABC’s • Do no harm • Pain management & sedation • Hyperventilation pCO2 30-35 mm Hg • Osmotic therapy • Ventricular drainage

  32. General Supportive Care HOB 30° SO2 ≥ 95% Glucose control ≤ 6.0 mmol T° control ≤ 37.5° C Pain control, sedation

  33. Hyperventilation • Regional blood flow • Oxygen extraction • But: CMRO2 stable ad pCO2 = 10 mm Hg • At the levels used in TBI, hyperV does not result in ischemia • Pressure autoregulation dysfunction is improved

  34. Hyperventilation • Present recommendation: • Avoid during 1st 24H post TBI • pCO2 30 – 35 mm Hg • If no response: 25 – 30 mm Hg

  35. Hyperventilation • My recommendation: • Use for acute ICHT, temporizing measure • pCO2 30 – 35 mm Hg 25 – 30 mm Hg • Has no associated ischemia ad pCO2 10 • Beware of hypoperfused areas that are more fragile

  36. Osmotic AgentsMechanisms of Action • Mannitol • BW in intact > affected brain • volume vasoconsriction • viscosity CBF vasoconstriction • size of CVA, apoptosis • HS • BW in intact = affected brain • Possible in size of CVA

  37. Osmotic AgentsClinical Use • Routinely recommended in edema of trauma and stroke • Lack of evidence of beneficial outcome • Little evidence of efficacy in stroke or ICH (especially Na)

  38. Osmotic AgentsClinical Use • Intermittent boluses allowing clearing of solute from blood. • Avoid continuous infusions • Smallest doses at the largest possible intervals, with prn according to ICP

  39. Osmotic AgentsClinical Use • ICH with ICHT: • MN first • HS if refractory, Cr, OG • Refractory to one agent: use the other • 250cc MN, then 100cc alternating MN/HS

  40. Treatment of ICHT • Intubation • Hyperventilation • Sedation • Steroids: NO role • Osmotic agents • Mannitol • Hypertonic saline  No Δ in outcome

  41. Hematoma Resection • STICH trial • ICH within a centimeter of the cortical surface showed a benefit for early surgery •  mortality, no other effect on morbidity • MISTIE: • Intra-lesion rtpa with subsequent aspiration

  42. Intra-ventricular Hemorrhage EVD Intra- ventricular rtpa (CLEAR)

  43. Intra-ventricular rTPA Hanley DF:pilot, prospective, randomized, double-blind, controlled trial • Speeds clearance of aneurysmal intraventricular hemorrhage • Normalizes intracranial pressure • Reduces ventricular catheter obstruction

  44. Early Hematoma Growth 2.0 hours after onset 6.5 hours after onset

  45. Prevent ICH Growth By  BP By rFVIIa

  46. Percent Change in ICH Volume at 24 Hours Boxes depict 98.3% confidence intervals 29% 16% 14% 11% 45% RR 52% RR 62% RR

  47. Modified Rankin Scale at Day 90 160 µg/kg 80 µg/kg mRS 0-1 mRS 2-3 mRS 4-5 40 µg/kg mRS 6 Placebo 0% 100% 80% 20% 40% 60%

  48. Hematoma Evolution and rFVIIa 3.3ml 4.5ml 5.8ml • rFVIIa within 4 hours: • Dose dependent attenuation of hematoma expansion • no effect on mRS at 90 days Mayer et al. NEJM 2005; 352: 777-85

  49. CTA Based rFVIIa Selection Trials • The SpoT sign fOr Predicting and treating ICH growTh study: STOP-IT SPOTRIAS/NINDS • PI: M. Flaherty • ‘SPOT sign’ seLection of Intracerebral hemorrhage to Guide Hemostatic Therapy: SPOTLIGHT CSN/ CIHR • PI: D. Gladstone Acute ICH < 6 hours CTA Spot Sign Positive Spot Sign Negative rFVIIa Placebo NCCT at 24 hours

  50. Seizure Prophylaxis Are seizures frequent post ICH ? Do they change outcome ? Does prophylaxis  frequency ? Does a  in Sz affect outcome ? Is therapy associated with adverse events ?

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