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Update from education committee

Comprehensive review discussing causes, workup, acute management, complications, and surgical/interventional treatments of acute intracerebral hemorrhage. Presented by expert speakers from KU School of Medicine and Genentech, Inc. Includes relevant clinical trials and best practices.

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Update from education committee

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  1. Update from education committee • Train the trainer—content reviewed from Overview of Acute Intracerebral Hemorrhage “First Tuesdays” Lecture Series

  2. Introduction and Goal of “First Tuesdays” • SabreenaSlavin MD – Vascular Neurologist and Neurohospitalist at KU School of Medicine • Craig Bloom RN, BSN, MBA – Senior Clinical Specialist Lytics, Genentech, Inc. • Didactic lecture series as part of the Kansas Initiative for Stroke Survival • Updates in Practice and FAQ’s on Acute Stroke Care • 20 minute didactic, 10 minutes for questions/discussion.

  3. Causes of ICH • Traumatic: located in frontal or temporal poles, may have associated skull defect • Hypertensive: located deep in basal ganglia/thalamus or in brainstem/cerebellum • Amyloid angiopathy: located in lobes, may have microhemorrhages on MRI • Anticoagulation-related • Vascular malformations (aneurysms, AVM's): element of subarachnoid hemorrhage/intraventricular hemorrhage • Ischemic stroke with hemorrhagic transformation: larger area of surrounding ischemia on MRI • Brain metastasis: mass on imaging

  4. Bell & Jones, Radiopaedia https://radiopaedia.org/articles/intracerebral-haemorrhage?lang=us

  5. Gaillard, Radiopaediahttps://radiopaedia.org/articles/cerebral-amyloid-angiopathy-1?lang=usGaillard, Radiopaediahttps://radiopaedia.org/articles/cerebral-amyloid-angiopathy-1?lang=us

  6. Workup • CBC and coagulation factors • MRI brain • CTA head • +/- cerebral angiogram

  7. Acute management • Stabilize patient • Call neurosurgery

  8. Acute management: blood pressure • INTERACT-2 trial1: patients with acute spontaneous ICH randomized to BP < 140 vs BP < 160 within 6hours. After adjustment of baseline ICH volume, no difference in ICH volume at 27 hours or mRS at 90 days.  ATACH-2 tirial2: patients with acute spontaneous ICH randomized to BP 110-139 vs 140-179 within 4.5hours. No significant difference in groups of expansion on 24 hour CT or 90 day mRS, but with moreadverse effects in the tight control group. • Would plan to keep SBP less than 160 for most patients • Caveat: if aneurysmal, keep SBP less than 140. 1. Anderson et al, N Engl J Med 2013; 2. Qureshi et al, N Engl J Med 2016.

  9. Acute management: anticoagulant reversal • Give PCC (prothrombin complex concentrate) • INCH trial: For ICH related to Vitamin K antagonists: PCC is better than FFP resulting in lower INRs, smaller hematomas at 24 hours, andless mortality (19% vs 35%) • Can also use for direct inhibitors (eg: Apixaban) • Idarucizumab (Praxbind): used to reverse Dabigatran (Pradaxa) • Andexxa: used to reverse Apixaban (Eliquis) or Rivaroxaban (Xarelto) Steiner et al, Lancet Neurol 2016

  10. Acute management: platelets? • PATCH trial: For ICH related to antiplatelet therapy: Platelet transfusion led to higher risk of death/dependency at 3 months and with more adverse events during hospital stay. • Do not give platelets Baharoglu et al, Lancet 2016

  11. Surgical/interventional treatment • EVD for patients at risk for hydrocephalus (eg: IVH) • Craniotomy to evacuate hemorrhage/endoscopic aspiration can be done with smaller areas of hemorrhage • Early surgery? STICH trial: RCT of 1033 patients with supratentorial ICH: no significant difference overall between early surgery and early conservative management. There was a significant benefit in subgroup with ICH 1 cm or less from surface. • In cases with aneurysms/AVM, cerebral angiogram to treat Mendelow et al, Lancet 2005

  12. Complications of ICH • Elevated ICP/impending herniation: can cause unstable vitals (Cushing's triad: hypertension, bradycardia, irregular respirations) • Seizures • Expanding hemorrhage: • Between initial CT and 24-hour CT, 14% of 627 patients had enlarging ICH in one study - associated with earlier admission, increased ETOH consumption, irregular size of hematoma, IVH, altered consciousness, and lower fibrinogen level Fujii et al, Stroke 1998

  13. Bottom Line • ICH can worsen quickly: Stabilize patient and call NSGY asap • Treat elevated BP to less than 160 • Get full list of medications from family (especially for anticoagulation agents) • Once stable, further workup including CTA and MRI can help in diagnosis

  14. Questions? • Call for help anytime! • KU BAT phone: 913-588-3727 • http://www.kissnetwork.us/ • sslavin2@kumc.edu

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