Nontraumatic Intracranial Hemorrhage: A Review and Update
Transcript of Nontraumatic Intracranial Hemorrhage: A Review and Update
Nontraumatic Intracranial Hemorrhage: A Review and UpdateAdam Griffith MDDepartment of NeurosurgeryThe Permanente Medical Group
Introduction
What is it?
2nd most common subtype of stroke
Stroke is now the fifth leading cause of death overall.
The leading cause of disability in the U.S.
10-30/100,000
Any given year, there are >5 million cases and >3 million deaths secondary to ICH worldwide 50% of all fatal cases occurring in the 1st 48hrs
<40% of patients regain functional independence
ICH 2010 KP
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Fresno
Rosevil
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Mantec
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Vacavill
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So Sac
Primary
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RWC
ICH (n)
ICH (n)
Learning Objectives and Outline
Etiology and Risk Factors
Presentation and Evaluation
Imaging and Workup
Management and Treatment Medical and Surgical
Anticoagulants/Antiplatelets
Case studies
Future
DISCLOSURE INFORMATION: The planners of this activity and the speaker, Adam Griffith, MD, do not have affiliations with any corporate organizations that may constitute a conflict of interest with this presentation.
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Important CME Information
Etiology and Risk Factors
Chronic HTN 50-70%
Cerebral amyloid angiopathy Older patients
Amyloid-β peptide and Apolipoprotein E
Coagulapathy-associated >15% of all cases
Antithrombotic/thrombolytic Congenital or acquired factor deficiencies
Underlying abnormality Aneurysm AVM Cerebral venous thrombosis and infarction
Tumors
Presentation
Presentation very similar to acute ischemic stroke
Sudden onset of a focal neurological deficit Certain clinical findings increase probability of ICH
Coma/decreased LOC, seizures accompanying deficit, DBP > 110, emesis, severe headache
Imaging
Neuroimaging CT +/- CTA +/- MRI(+/- MRA)
In hypertensive patients >65 with well-circumscribed hematoma located in BG/thalamus, the yield of CTA/MRI/MRA is low(2-3%), so decision not to proceed may be reasonable
If a patient has a small cerebellar infarct/small hemorrhage without mass effect and is comatose, then neurovascular studies are needed to exclude basilar artery occlusion
CTA and the “Spot sign”
DSA is the gold standard but with increasing accuracy, CTA is 95-100% accurate in determining secondary causes
Hematoma Location
Initial Management of ICH Airway – can patient protect airway? Is intubation needed?
CT head noncontrast
Consider CTA in selected cases
STAT labs including INR, platelet count, PTT
Emergent reversal of anticoagulant induced coagulopathy if patient is on warfarin or TSOAs (use “Neurosurgical Rapid Reversal of Coagulopathy” order set)
Blood pressure control
Intracranial pressure - are there clinical and/or radiographic signs of ICP elevation?
7 .
Initial Management of ICH - ICH expansion Occurs early (first 6 hours) and often
Seen in about 30-40% of patients in the first 24 hours
Seen in much higher % of patients if on anticoagulants
Amount of expansion and associated clinical decline is quite variable
The ‘ugly truth’ is that this can happen, research has not found a way to stop it, and that the care is essentially supportive
7 .
BP Management in ICH/SAH Tight control recommended for patients at risk of ICH/SAH
rebleeding such as AVM, aneurysm (typically SBP 100-150)
Super-tight control of BP not helpful (See below from ATACH-2; please note that study trial standard treatment was well below SBP 180)
In patients with suspected ICP (increased intracranial pressure), recommend discussing BP goal with Neurosurgery
7 .
Anticoagulant-associated ICH
Increasing use>>>currently a 3-fold increase in incidence of ICH Pts have increased risk for hematoma expansion and higher risk of death and
poor outcome
Warfarin 9-14% of all cases of ICH
Emergent Reversal of Warfarin Induced Coagulopathy
Vit K 10 mg IVK Centra (“high octane, concentrated
FFP on steroids”)For Jehovah’s witnesses, consider
recombinant Factor VII
7 .
***USE “Neurosurgical Rapid Reversal of Coagulopathy”
order set It has “everything” you need
Emergent Reversal of TSOA Induced Coagulopathy
For patients on dabigatran(direct thrombin inhibitor), use idarucizumab (Praxbind)
For patients on apixaban, rivaroxaban, edoxaban (oral direct Xainhibitors), use Kcentra
In the future, we anticipate FDA approval of andexanet alfa
***USE “Neurosurgical Rapid Reversal of Coagulopathy” order set
It has “everything” you need
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How about ICH Patients on Antiplatelet therapy?
The only 1 randomized control trial to address platelet transfusion in ICH associated with antiplatelet use (PATCH – Platelet Transfusion in Cerebral Hemorrhage) showed no evidence of benefit and a trend toward harm
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Platelet pheresis for all patients on dual antiplateletsPlatelet pheresis for all patients with symptomatic subdural hematomas on antiplatelet agentsUse of platelet pheresis products for low dose aspirin or NSAIDs for patients who need urgent neurosurgical procedures (EVD, burr holes, craniotomies)Others on a case by case basis
COMMENTS REGARDING PATCH TRIAL• Almost no patients in trial on dual antiplatelet agents• Patients in platelet transfusion group had higher mortality rates but there
were no significant platelet transfusion reactions to explain this• This study has not been replicated• No use of platelet function tests to determine presence/degree of
platelet dysfunction
Role of Surgical management
If hydrocephalus is present with or without intraventricularhemorrhage, a ventriculostomy is usually performed.
Decompressive suboccipital craniectomy (with or without ventriculostomy) should be strongly considered for cerebellar ICH > 3 cm in diameter.
In non-cerebellar hemorrhages, there is no evidence that surgical evacuation of ICH benefits patients. Two RCTs, STICH and STICH II, failed to find a benefit of surgical
hematoma evacuation by craniotomy compared to medical therapy.
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Predicting Outcome of ICH:The ICH Score 0-6pt scale
GCS Given more weight as it was
found to be the strongest independent predictor
Age
ICH
IVH
Infratentorial ICH
Measuring ICH volume
Calculating ICH volume (AxBxC)/2
A = greatest hemorrhage diameter by CT B = diameter perpendicular to A C = approximate number of CT slices with hemorrhage
multiplied by the slice thickness in cm If a slice contains >75% of ICH area seen on the slice with the
greatest amount of ICH, it is counted as 1 slice If between 25 % and 75%, then as ½ slice If <25%, then it is not counted
ICH Volume and Intraventricular Hemorrhage
Both have strong independent associations with outcome
Hematoma Volume of 30ml is the cutoff Increased mortality
Worse functional outcome
Presence of IVH associated with a lower probability of favorable outcome
ICH score to help guide prognosis early on
Surgery rarely indicated(except for those requiring EVD placement for IVH and infratentorial hemorrhages)
Restarting Anticoagulants in Patients with ICH
Many factors are considered in making this decision, the most important one being the cause of ICH and expected risk of recurrence, and the patient’s risk of future thromboembolic events. For example: The risk of recurrence of ICH may be lower in non-lobar hemorrhages
versus lobar hemorrhages and with well-controlled hypertension.
In patients with a history of symptomatic ICH and atrial fibrillation with high risk estimation scores (such as > 5 on CHADS2), anticoagulation may still be an appropriate treatment option
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Other issues/therapies
Na—no definite research showing appropriate level Normal sodium unless those cases when ICP is a concern150
Glucose—Target remains to be clarified—keep normal, avoid hypoglycemia
Temperature—avoid fever, keep <38; therapeutic cooling has not been systematically investigated in ICH pts
AEDs—clinical seizures should be treated EEG monitoring for those pts with decreased mental status out of proportion to
degree of brain injury
Prophylactic anticonvulsant medication should not be used
Case Studies
63yo M
Progressive headache over 3 days and left blurriness of vision
Left incomplete homonymous hemianopsia
CTA negative
6wk scan
77yo F on Coumadin for A fib along with other multiple medical problems
Presented with acute onset of confusion, headache, and left-sided hemiparesis
Long extended course in ICU and floor
Required readmission for respiratory failure
SNF, now in rehab
Ambulating with a walker for short distances
Required PEG initially but now eating on her own
47yo M
Acute speech disturbance, dense hemiparesis => unresponsive
Large left BG hemorrhage
GCS 4 on exam
Poor outcome
49yo M off HCTZ for a week p/w n/v
SBP >200
43yo M with ETOH abuse p/w headache, vomiting, ataxia
OR for EVD and decompression
Future
Reversal agent for factor Xa inhibitors
MISTIE-III trial
Minimally invasive surgical evacuation of deep hematomas
Summary
Noncontrast CT head scan +/- CTA If confirmed underlying vascular abnormality(eg aneurysm), then
decision with nsgy to transfer to Morse Ave for further care
SBP goal <150
Emergent reversal of anticoagulant induced coagulopathy if patient is on warfarin or TSOAs (use “Neurosurgical Rapid Reversal of Coagulopathy” order set
Prophylactic anticonvulsant medication should not be used
Role of surgical management limited(except for those with IVH and hydrocephalus requiring EVD placement and infratentorialhemorrhages)
Questions??
Works Cited
Aguilar, Maria and Thomas Brott. Update in Intracerebral Hemorrhage. The Neurohospitalist. 2011; 3: 148-159.
de Oliveira Manoel et al. Critical Care (2016) 20:272. DOI 10.1186/s13054-016-1432-0
Le Roux, P. et al. Race Against the Clock: Overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage. J Neurosurg. 2014; 121:1-20.
Morganstern, L. et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. (2010) 41:2108-2129. DOI 10.1161/STR.0b013e3181ec611b
Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009;373(9675):1632–44. doi:10.1016/S0140-6736(09)60371-8.
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