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Intracerebral Hemorrhage

Intracerebral 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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Intracerebral Hemorrhage

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  1. Intracerebral 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. Key Clinical Questions • What's the optimal ED management of a patient with ICH? • What are the goals of BP management? • Why is ICP important? • What are the optimal strategies for managing ICP? • What other treatment modalities are available to the ED physician?

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

  12. NY Times

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

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

  15. Intracranial Hemorrhage • Diagnosis • Treatment • ICP • BP management • Medical management • Neurosurgical indications • New treatment modalities

  16. ICH Epidemiology • 30 day mortality: 30-40% • 50% of these in first 48 hours • One-fifth of survivors are independent at 6 months • 7000 operations annually in USA to remove blood

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

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

  19. 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 pCO2-30

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

  21. Initial ED Therapy • Resuscitation of the patient-regardless of ICP • Assume elevated ICP in head injury/altered MS patient • ABCs-as all good ED physician would do

  22. Key Concept • Cerebral blood flow: 1. Intracranial pressure • Elevated when ICP >20 mm Hg 2. Cerebral perfusion pressure • CPP=MAP-ICP • Maintain CPP > 70 mm Hg • Example: MAP = 100, ICP = 20 • CPP in above example = 80 mmHg

  23. Increased ICP Risk • Intracranial Pressure (ICP): considered a major contributor to mortality when elevated • Correlation between elevated ICP and poor outcome • Increased risk of • Herniation • Decreased Cerebral perfusion

  24. Increased ICP Treatment Controlling ICP is considered essential • Osmotherapy • Hyperventilation • Barbiturate coma

  25. Clinical ICP Assessment • For those without access to emergent ICP monitors • Pupils size and reactivity • Neurological status-deterioration vs. improvement

  26. NIH Stroke Scale NIH Stroke Scale

  27. ICP Monitors • GCS less than 9 • All patients whose condition is thought to be deteriorating due to elevated ICP Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999, 905-915

  28. Osmotherapy • Osmotherapy-Mannitol • Reduces ICP by decreasing cerebral fluid volume • Rebound effect-use less than 5 days • Intermittent Bolus-not continuous infusion • 0.5-1.0 mg/kg maintain serum osmolarity < 310-320 mOsm/L • Renal failure • Volume depletion (make sure patient has a Foley)

  29. HOB Elevation • Elevate head of bed-decrease ICP • Mechanical-helps drain blood by gravity • Keep neck in neutral position • Do not obstruct venous outflow • Do not allow blood to pool in cranium, which may occur if patient is left laying flat

  30. Endotracheal Intubation • Intubation-not required, but airway protection and adequate ventilation are necessary • Rely on clinical suspicion, not GCS • Decreases ICP by decreasing CBF • pCO2 should be kept around 30-35 • Avoid PCO2 less than 30 • Decrease CBF to ischemia without further lowering ICP • Beneficial effect of sustained hyperventilation is not proven

  31. Lidocaine • 1.5 mgs/kg • Depresses cough reflex • Blocks increases in ICP of intubated patients with space occupying lesions • Give 3 minutes before laryngoscopy Lev, R, Rosen,Pp; Prophylactic Lidocaine Use Preintubation: A review: JOEM Vol 12 No 4 499-506

  32. Paralytics/Sedation • Recommended: • prevents increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT • Avoids ICP spikes-elevated ICP correlated to poor outcome

  33. Barbituate Coma • Lowers ICP via lowering Cerebral metabolism • Use when other therapies fail • No evidence of improved outcome

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

  35. SBP and ICH Incidence Incidence Rate/100,000 Systolic Blood Pressure (mmHg)

  36. BP Management • Maintain blood pressure 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 • Cerebral perfusion pressure (MAP-ICP) should be kept > 70 mm Hg Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999, 905-915

  37. BP Management • Labetalol • Repetitive I.V. boluses of 20-80 mg q. 10 min or constant infusion of 0.5-2.0 mg/min • Nicardipine • 5-15 mg/hr I.V. infusion Update on management of intracerebral hemorrhage; Neurosurg Focus 15; 2003 1-6

  38. Nipride • Nipride • 0.5-1.0 mics/kg/min • Theoretically can increase cerebral blood flow and thereby intracranial pressure

  39. BP Management • Avoid hypotension • If systolic BP drops to less than 90 mmHg • fluid boluses-isotonic saline or colloids • Pressors • Phenylephrine, dopamine, Norepinephrine Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999, 905-915

  40. Hypotension • Do not let Systolic BP fall below 90 • Hypoxemia • Deleterious outcome 717 patients prospectively collected data set from Traumatic Coma Data bank • May be more important than hypertension

  41. Cerebral Blood Flow Neurology: July, 2001 18-24

  42. Cerebral Blood Flow

  43. CBF: Conclusions • In patients with small to medium sized acute ICH, autoregulation of CBF was preserved with arterial pressure reductions. • Qureshi;Critical Care Medicine. 27(5):965-971, May 1999- • 18 mongrel dogs • Reduction of MAP within normal autoregulatory limits of CPP had no adverse outcome on ICP or regional blood flow

  44. 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

  45. 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 temperature > 38.5˚ C • Acetaminophen or a cooling blanket best options.

  46. Seizure Therapy • Neuronal injury may lead to seizures • Nonconvulsive seizures may contribute to coma in up to 10% of patients • Consider prophylactic antiepileptic therapy in setting of ICH • Lobar hemorrhage-35% seizure rate • Fosphenytoin or phenytoin Broderick: Guideline for the Management of Spontaneous Intracerebral Hemorrhage; Stroke 4, 1999, 905-915

  47. Seizure Therapy • No consensus exists on when to withdraw anticonvulsant therapy • If no seizure activity-withdraw at one month Fewel: Spontaneous Intracerebral Hemorrhage: A Review; Neurosurg Focus 15 (4), 2003

  48. Medical Therapy • Euvolemia • Isotonic crystalloid solutions • Electrolyte abnormalities • Correct deficits • Glucose management- >140 start insulin

  49. Medical Therapy • ABG • Correct hypoxemia, hypercapnia • Correct acid/base disorders • Coagulopathy • Correct INR • Correct Platelet counts

  50. Steroids • Controversial • Three studies (159 patients)-no benefit • Tellez H, Bauer RB: Dexamethasone as treatment in cerebrovascular disease. 1. A controlled study in intracerebral hemorrhage. Stroke 4:541–546, 1973 (40) • Poungvarin N, Bhoopat W, Viriyavejakul A, et al: Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 316:1229–1233, 1987 (93) • Desai P, Prasad K. Dexamethasone is not necessarily unsafe in Primary Supratentorial Cerebral Hemorrhage. J Neurol Neurosurg Psychiatry. 1998;65:799-800 (26) • Neurosurgerical literature • Use when evidence of vasogenic edema and mass effect Update on management of intracerebral hemorrhage; Neurosurg Focus 15; 2003 1-6

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