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The Pathophysiology And Management Of Hemorrhagic Stroke

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  • 1. Continuous Medical Education Department of Neurosurgery, HKL 14 February 2007 The Pathophysiology and Management of Hemorrhagic Stroke
  • 2. EPIDEMIOLOGY
    • For a patient who presents with the abrupt onset of a new focal neurological deficit :
    • 5% are seizure, tumour or psychogenic
    • 95% are vascular
      • 15% haemorrhagic
        • ICH, SAH, SDH
      • 85% ischaemic infarct
        • Unknown, lacunar, cardiogenic embolus, large artery cerebrovascular lesion, tandem arterial pathology, atherosclerotic plaques in the aortic arch
  • 3. EPIDEMIOLOGY
    • Incidence 12-15/100,000/yr
    • Intracerebral hemorrhage (ICH) is more than twice as common as subarachnoid hemorrhage (SAH)
    • Much more likely to result in death or major disability than cerebral infarction or SAH
    • 35% to 50% can be expected to die within the first month after bleeding
    • Only 10% of patients are living independently 1 month after the hemorrhage
    • 20% are independent at 6 months
  • 4. EPIDEMIOLOGY
    • Risk factors
      • Advancing age and hypertension are the most important risk factors
      • Age : >after 55, doubles with each decade
      • Gender : more common in men
      • Ethnic : More common among young and middle-age
      • blacks than whites of similar ages
      • More common in Asians compared to whites
      • Previous CVA increases risk by 23:1
      • Alcohol consumption
      • Drug abuse
      • Liver dysfunction
  • 5. EPIDEMIOLOGY
    • Causes of Intracranial Haemorrhage
    • Primary ( hypertensive ) intracerebral haemorrhage
    • Ruptured saccular aneurysm
    • Ruptured AVM
    • Haemorrhagic disorders ( leukaemia, aplastic anaemia, anticoagulant therapy, haemophilia..)
    • Haemorrhage into brain tumours
    • Septic embolism
    • Haemorrhagic infarct
    • Inflammatory diseases of blood vessels
    • Amyloidosis
  • 6. EPIDEMIOLOGY
    • Locations of haemorrhage
      • Putamen, lenticular nucleus, internal capsule, globus pallidus 50%
      • Thalamus 15%
      • Pons 10-15%
      • Cerebellum 10%
      • Cerebral white matter 10%
      • Brain stem 6%
    • Common arterial feeders of ICH
      • Lenticulostriates – putaminal
      • Thalamoperforators
      • Paramedian branches of the basilar artery
  • 7. EPIDEMIOLOGY
    • Lobar haemorrhage vs deep haemorrhage
      • Haemorrhage into the occipital, temporal, frontal and parietal lobes as opposed to deep structures – BG, thalamus, infratentorial structures
      • More likely associated with structural abnormalities
      • More common in patients with high alcohol consumption
      • More benign outcome
      • Causes
        • Extension of deep haemorrhage
        • Cerebral amyloid angiopathy
        • Trauma
        • Haemorrhagic transformation
        • Tumour
        • AVM/aneurysm
  • 8. PATHOPHYSIOLOGY
    • Chronic hypertension stimulates the brain's blood vessels to make gradual, adaptive changes in an attempt to preserve the blood-brain barrier
    • One gradual change that may develop is lipohyalinosis
    • Subintimal fibroblast proliferation occurs, with an accumulation of lipid-laden macrophages and cholesterol deposits; this results in hyalinization and lipidosis of the blood vessels
    • This process segmentally affects the smaller penetrating arteries (<200 mm in diameter)
  • 9. PATHOPHYSIOLOGY
    • Plasma leakage from persistently elevated blood pressures also can result in hyaline degeneration of the cerebral blood vessels
    • Arterial sclerosis and fibrinoid necrosis may occur, as well as focal aneurysmal dilatation (Charcot-Bouchard intracerebral microaneurysm)
    • Hemorrhage may then arise from rupture of the Charcot-Bouchard aneurysms
  • 10. Management
    • CT of the head is the imaging procedure of choice in the initial evaluation of suspected ICH
    • Angiography should be considered for all patients without a clear cause of hemorrhage who are surgical candidates , particularly young, normotensive patients who are clinically stable.
    • Angiography is not required for older hypertensive patients who have a hemorrhage in the basal ganglia, thalamus, cerebellum, or brain stem and in whom CT findings do not suggest a structural lesion
    Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (1999 American Heart Association )
  • 11.
    • 4. MRI and MRA are helpful and may obviate the need for contrast cerebral angiography in selected patients. They should also be considered to look for cavernous malformations in normotensive patients with lobar hemorrhages and normal angiographic results who are surgical candidates
    Management Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (1999 American Heart Association )
  • 12. Management - Treatment
    • Medical
    • Surgical
    • There is a lack of proven medical or surgical treatment for ICH
    • This has lead to great variation among physicians concerning both surgical and medical treatment
    • Well-designed and well-executed randomized treatment studies of ICH are urgently needed
  • 13. Management - Treatment
    • Medical
    • Airway and oxygenation
    • Blood pressure
    • ICP
    • Fluid management
    • Prevention of seizures
    • Body temperature
    • Other issues
  • 14. Management - Treatment
    • Airway and oxygenation
    • Although intubation is not required for all patients, airway protection and adequate ventilation are critical
    • Patients who exhibit a decreasing level of consciousness or signs of brain stem dysfunction are candidates
    • Intubation should be guided by imminent respiratory insufficiency rather than an arbitrary cutoff such as a specific Glasgow Coma Scale (GCS) score
        • “ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
        • by the American Heart Association 1999
  • 15. Management - Treatment
    • Indications for intubation
      • hypoxia (pO2 <60 mm Hg or PCO2 >50 mm Hg)
      • risk of aspiration with or without impairment of arterial oxygenation
    • All patients with endotracheal tubes receive nasogastric or orogastric tubes to prevent aspiration and are monitored for cuff pressure every 6 hours
    • Endotracheal tubes with soft cuffs can generally be maintained for 2 weeks
        • “ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
        • by the American Heart Association 1999
  • 16. Management - Treatment
    • In the presence of prolonged coma or pulmonary complications, elective tracheostomy should be performed after 2 weeks
    • Oxygen should be administered to all patients presenting with a possible ICH
        • “ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
        • by the American Heart Association 1999
  • 17. Management - Treatment
    • Blood Pressure
    • Optimal level of a patient's blood pressure should be based on individual factors
      • Chronic hypertension
      • Raised ICP
      • Cause of haemorrhage
    • The theoretical rationale for lowering blood pressure is to decrease the risk of on going bleeding from ruptured small arteries and arterioles
    • Conversely, over aggressive treatment of blood pressure may decrease cerebral perfusion pressure and theoretically worsen brain injury
        • “ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
        • by the American Heart Association 1999
  • 18. Management - Treatment
    • Blood pressure levels be maintained below a mean arterial pressure of 130 mm Hg in persons with a history of hypertension (level of evidence V, grade C recommendation)
    • In patients with elevated ICP who have an ICP monitor, cerebral perfusion pressure (MAP–ICP) should be kept >70 mm Hg (level of evidence V, grade C recommendation)
    • Mean arterial blood pressure >110 mm Hg should be avoided in the immediate postoperative period
    • If systolic arterial blood pressure falls below 90 mm Hg, pressors should be given
        • “ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
        • by the American Heart Association 1999
  • 19. Titrate from 0.05–0.2 µg · kg -1 · min -1 Norepinephrine 2–20 µg · kg -1 · min -1 Dopamine 2–10 µg · kg -1 · min -1 Phenylephrine Volume replenishment is the first line of approach. Isotonic saline or colloids can be used and monitored with central venous pressure or pulmonary artery wedge pressure. If hypotension persists after correction of volume deficit, continuous infusions of pressors should be considered, particularly for low systolic blood pressure such as <90 mm Hg. Low blood pressure 4. If ICP monitoring is available, cerebral perfusion pressure should be kept at >70 mm Hg. 3. If systolic BP is <180 mm Hg and diastolic BP <105 mm Hg, defer antihypertensive therapy. Choice of medication depends on other medical contraindications (eg, avoid labetalol in patients with asthma). 2. If systolic BP is 180 to 230 mm Hg, diastolic BP 105 to 140 mm Hg, or mean arterial BP 130 mm Hg on 2 readings 20 minutes apart, institute intravenous labetalol, esmolol, enalapril, or other smaller doses of easily titratable intravenous medications such as diltiazem, lisinopril, or verapamil. 1. If systolic BP is >230 mm Hg or diastolic BP >140 mm Hg on 2 readings 5 minutes apart, institute nitroprusside. 0.625–1.2 mg Q 6 h as needed Enalapril 10–20 mg Q 4–6 h Hydralazine 0.5–10 µg · kg -1 · min -1 Nitroprusside 500 µg/kg as a load; maintenance use, 50–200 µg · kg -1 · min -1 Esmolol 5–100 mg/h by intermittent bolus doses of 10–40 mg or continuous drip (2–8 mg/min) Labetalol Elevated blood pressure
  • 20. Management - Treatment
    • ICP
    • ICP may be managed through head position, osmotherapy, controlled hyperventilation, and barbiturate coma
    • Elevated ICP is defined as intracranial pressure 20 mm Hg for >5 minutes
    • A therapeutic goal for all treatment of elevated ICP is ICP <20 mm Hg and cerebral perfusion pressure (CPP) >70 mm Hg
    • Patients with suspected elevated ICP and deteriorating level of consciousness are candidates for invasive ICP monitoring
        • “ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
        • by the American Heart Association 1999
  • 21. Management - Treatment
    • In general, ICP monitors should be placed in (but not limited to) patients with a GCS score of <9 and all patients whose condition is thought to be deteriorating due to elevated ICP (level of evidence V, grade C recommendation)
    • Ventricular drains should be used in patients with or at risk for hydrocephalus
    • Because of infectious complications, external drainage devices must be checked regularly , and duration of placement ideally should not exceed 7 days (level of evidence V, grade C recommendation)
        • “ Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
        • by the American Heart Association 1999
  • 22. Management - Treatment
    • Use of anti-infectious prophylaxis is recommended (level of evidence V, grade C recommendation)
    • The beneficial effect of sustained hyperventilation on ICP is unresolved
    • When hyperventilation is deemed no longer necessary, gradual normalization of serum PCO2 should occur over a 24- to 48-hour period
    • In general, if hyperventilation is instituted for elevated ICP, PCO2 should be maintained between 30 and 35 mm Hg until ICP is controlled
  • 23. Emergency ICP therapy
      • Comatose patient with clinical signs of brainstem herniation
        • Head up 30 degree
        • Mannitol 20% 1-1.5gm/kg
        • Hyperventilation Pco2 30-35 mmHg
      • “ Buy time” before a definitive neurosurgical procedure
  • 24. Management of ICP
    • Osmotherapy
      • The first medical line of defense is osmotherapy. However, it should not be used prophylactically .
      • Mannitol 20% ( 0.25–0.5 g/kg every 4 h ) is reserved for patients with type B ICP waves , progressively increasing ICP values, or clinical deterioration associated with mass effect (level of evidence V, grade C recommendation).
      • Due to its rebound phenomenon, mannitol is recommended for only 5 d.
      • To maintain an osmotic gradient, furosemide (10 mg Q 2–8 h) may be administered simultaneously with osmotherapy.
      • Serum osmolality should be measured twice daily in patients receiving osmotherapy and targeted to 310 mOsm/L.
  • 25. Management of ICP
    • No steroids
      • Corticosteroids in ICH are generally avoided because multiple potential side effects must be considered and clinical studies have not shown benefit (level of evidence II, grade B recommendation).
  • 26. Management of ICP
    • Hyperventilation
      • Hypocarbia causes cerebral vasoconstriction.
      • Reduction of cerebral blood flow is almost immediate, although peak ICP reduction may take up to 30 minutes after pCO2 is changed.
      • Reduction of pCO2 to 35–30 mm Hg, best achieved by raising ventilation rate at constant tidal volume (12–14 mL/kg), lowers ICP 25% to 30% in most patients (levels of evidence III through V, grade C recommendation).
      • Failure of elevated ICP to respond to hyperventilation indicates a poor prognosis.
  • 27. Management of ICP
    • Muscle relaxants
      • Neuromuscular paralysis in combination with adequate sedation can reduce elevated ICP by preventing increases in intrathoracic and venous pressure associated with coughing, straining, suctioning, or &quot;bucking&quot; the ventilator (levels of evidence III through V, grade C recommendation).
      • Nondepolarizing agents, such as vecuronium or pancuronium, with only minor histamine liberation and ganglion-blocking effects, are preferred in this situation (levels of evidence III through V, grade C recommendation).
      • Patients with critically elevated ICP should be pretreated with a bolus of a muscle relaxant before airway suctioning. Alternatively, lidocaine may be used for this purpose.
  • 28. Management of ICP
    • Barbiturate Coma
      • Short acting thiopental 2-5 mg/kg slow stat then 1-5mg/kg/hour
      • Decreased cerebral metabolism, decreased CBF and CBV
      • Beware of hypotension
      • Max reduction in cerebral metabolism is accompanied by electrocerebral silence
  • 29. Management - Treatment
    • Fluid Management
    • The goal of fluid management is euvolemia
    • CVP should be maintained between 5 and 12 mm Hg or pulmonary wedge pressure at 10 to 14 mm Hg
    • Fluid balance is calculated by measuring daily urine production and adding for insensible water loss (urine output plus 500 mL for insensible loss plus 300 mL per degree in febrile patients)
    • Electrolytes (sodium, potassium, calcium, and magnesium) should be checked and substituted according to normal values
  • 30. Management - Treatment
    • Prevention of Seizures
    • Seizure activity can result in neuronal injury and destabilization of an already critically ill patient and must be treated aggressively
    • In patients with ICH, prophylactic antiepileptic therapy (preferably phenytoin with doses titrated according to drug levels [14 to 23 µg/mL]) may be considered for 1 month and then tapered and discontinued if no seizure activity occurs during treatment, although data supporting this therapy are lacking (level of evidence V, grade C recommendation)
  • 31. Management - Treatment
    • Body Temperature
    • Body temperature should be maintained at normal levels
    • Acetaminophen 650 mg or cooling blankets should be used to treat hyperthermia >38.5° C
    • Febrile patients or those at risk for infection, appropriate cultures and smears (tracheal, blood, and urine) should be obtained and antibiotics given
    • Nutrition
    • Enteral feeding should be started within 48h to reduce risk of malnutrition
  • 32. Management - Treatment
    • DVT prevention
      • Dynamic compression stockings should be placed on admission
      • Medications at day 2
        • SC heparin 5000u bd
        • LMW heparin enoxaparin 40 mg daily
        • No increased in intracranial bleeding
        • Boeer A, Voth E, Henze T, Prange HW. Early heparin therapy in patients with spontaneous intracerebral haemorrhage.
        • J Neurol Neurosurg Psychiatry 1991; 54: 466–67.
  • 33. Reversal of coagulation
      • Warfarin – increase risk of ICH 5-10X
        • Reverse with FFP & Vit K
      • Aim INR <1.4
      • Low molecule heparin
        • Reverse with protamine sulfate 1mg to 1 mg enoxaparin
  • 34. Management - Treatment
    • Other Issues
    • Many patients who are delirious or stuporous are agitated
    • Prudent use of minor and major tranquilizers is recommended
    • Short-acting benzodiazepines or propofol are preferred
    • Pulmonary embolism is a common threat during the recovery period, particularly for bedridden patients with hemiplegia. Pneumatic devices decrease the risk of pulmonary embolism during hospitalization
    • Depending on the patient's clinical state, physical therapy, speech therapy, and occupational therapy should be initiated as soon as possible
  • 35. Management - Treatment
    • Surgical Treatment
    • Management of cerebral haemorrhage - Karolinska Stroke Update Consensus Statement 2004
    • As yet, an advantage of neurosurgical intervention over medical treatment has not been established
  • 36. Surgical Treatment
    • ICH Treatment Targets
    • • Expanding hematoma
    • – Local shear forces
    • – Mass effect
    • – ↑ Intracranial pressure (ICP)
    • • Local toxic effects
    • – Direct toxicity of blood products
    • – Edema
    • – Excitotoxicity
  • 37. Management - Treatment
    • Recently, three RCTs evaluating new strategies for the treatment of the ICH have been completed.
      • a.     Early surgery versus initial conservative treatment in patients with spontaneous supratentorial ICH (The International STICH trial);
      • b.    Stereotactic aspiration combined with instillation of fibrynolitic agent (The SICHPA trial);
      • c.    Ultra-early haemostatic therapy by using the recombinant activated factor VIIa (The Novo-7 trial)
  • 38.
    • Comparison between early surgery combined hematoma evacuation (within 24 hours of randomization) with medical treatment.
    • FINDINGS: A total of 1,033 patients from 83 centers in 27 countries were randomized to early surgery (503) or initial conservative treatment (530). At 6 months, 51 patients were lost to follow-up, and 17 were alive with unknown status. Of 468 patients randomized to early surgery, 122 (26%) had a favorable outcome compared with 118 (24%) of 496 randomized to initial conservative treatment (odds ratio 0.89, 95% confidence interval 0.66 –1.19, P .414); absolute benefit 2.3% (–3.2 to 7.7), relative benefit 10% (–13 to 33).
    • INTERPRETATION: Patients with spontaneous supratentorial intracerebral hemorrhage in neurosurgical units show no overall benefit from early surgery when compared with initial conservative treatment.
    Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomized trial Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH investigators. Lancet 2005;365:387–97.
  • 39. Management - Treatment
    • The results of SICHPA trial ( Stereotatactic Treatment of Intracerebral Haematoma by means of a Plasminogen Activator
    • The trial was prematurely stopped because of low recruitment. A cautious conclusion could be made that stereotactic aspiration of supratentorial hematoma after instillation of a plasminogen activator can be performed safely. It may reduce the hematoma volume significantly
  • 40. Management - Treatment
    • Main results of Novo-7 trial
    • Treatment with rFVIIa within 4 hours reduced hematoma expansion, decreased mortality, and improved clinical outcome significantly, despite slight increase in the risk of thromboembolic events.
    • A phase III trial is needed to confirm the beneficial effect of rFVIIa in acute ICH
      • FAST trial – phase 3
      • Doses 20, 80 ug/kg
      • Within 4 hour of ictus
  • 41. Criteria for surgery
    • Age
    • Hematoma Volume
    • Location (Supra / Infratentorial)
    • Progression
    • Timing of surgery
  • 42. Age
    • Predictive role in outcome and mortality rate in patients with ICH 10
    • Age older than 60 years implies poor prognosis regardless of treatment
      • Mortality rate (surgically treated): (Auer LM et al, J Neurosurgery, 1989)
        • <60 years old 25%
        • >60 years old 65%
    • The relationship between age and outcome more pronounced with thalamic hemarrhage 10
    • Patients with “rapidly progressive*” hematoma by serial CT scan, age older than 65 years was associated with 100% mortality 10
    • Patients who were obtunded or stuporous without herniation signs
    • 10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768
  • 43. Hematoma Volume
    • Volume of hematoma based on CT scan measurement is a strong predictor of functional outcome and death. 10
    • [Volume = 4/3 x Π x LWH ÷ 8 or LWH ÷ 2]
    • Broderick et JP, Brott TG, Duldner JE, et al: Volume of ICH: A powerful and easy-to-use predictor of 30-day mortality. Stroke 24:987-993, 1993
    10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 71% 60% 7% Lobar 93% 64% 23% Deep >60cm3 30-60cm3 <30cm3 Mortality
  • 44. Hematoma Volume
    • Volpin et al, Neurosurgery (1984) retrospective reviewed of 132 patients with supratentorial ICH,
      • those with hematoma volume >85cm3 have 100% mortality irrespective of treatment
      • Those with hematoma volume <26cm3, all survived without surgery
    • Large-volume thalamic hematoma are more devastating than similar sized subcortical or putaminal hematomas 10
    • For infratentorial hematoma, all cerebellar hematoma greater than 3 cm in diameter is recommended for surgery 10
    10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768
  • 45. Progression
    • Broderick et al (1993) and Fujitsu K et al (1990) found that rehemorrhage typically occurs within the first 6 hours of the primary ictus
    • Deterioration occur later than 6 hours after hemorrhage can be contributed by other factors such as edema, hydrocephalus, new IVH or metabolic abnormality.
    • Patients’ clinical severity at 6 hours most accurately represented the severity of the ictus:
      • Fulminant - Poor outcome despite treatment
      • Rapidly progressive - outcome improved with hematoma evacuation
      • Slowly progressive - no significant difference in outcome based on treatment
    Fulminant = comatose, obtunded, herniation signs Slowly progressive = lethargy at 6 hours
  • 46. Timing of Surgery
    • In the case of spontaneous ICH, earlier interventions would intuitively appear superior
    • Early evacuation of hematoma improves CBF, brain edema, ischemia, and outcome.
    • It is supported by the following facts:
      • 50% death of patient with ICH occur within 48 hours of hemorrhage
      • Radiographic expansion or rebleeding occurs maximally within 3-4 hours
      • Exacerbation occurs suddenly and most often within 4 to 6 hours of bleeding
      • Secondary changes such as edema occur 7 to 8 hours after a hemorrhage
  • 47. Timing of Surgery
    • Brott T et al. Stroke . 1997; Early hemorrhage expansion is common. ~1/3 of patients who present within 3 hours of symptom onset will have substantial ICH expansion
  • 48. Timing of Surgery
    • Kaneko and colleagues[1983] also demonstrated superior outcomes (relative to epidemiological data) when they reported a 6-month 7% mortality rate in a series of patients with 100 putaminal ICHs treated surgically within 7 hours of ictus
    • Zuccarello M, Brott T, Derex, et al [1999] and Morgenstern LB, Frankowski RF, Shedden P, Pasteur W, Grotta JC; Surgical treatment for intracerebral hemorrhage (STICH), [1998] are 2 pilot studies suggested a benefit with early surgery (<12 hours) but were limited by small numbers.
    • Morgenstern and colleagues[2001] showed that ultra-early surgery (that is, 4 hours after ICH) is associated with increased re-hemorrhage and mortality rates
    • A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours) was stopped after interim analysis because of an increased rate of rebleeding.2
    2 Neurosurg Focus 15 (4):Article 2, 2003, Update on management of intracerebral hemorrhage, NADER POURATIAN, M.D., PH.D., NEAL F. KASSELL, M.D., AND AARON S. DUMONT, M.D.
  • 49. Timing of Surgery
    • Kaneko and colleagues[1983] also demonstrated superior outcomes (relative to epidemiological data) when they reported a 6-month 7% mortality rate in a series of patients with 100 putaminal ICHs treated surgically within 7 hours of ictus
    • Zuccarello M, Brott T, Derex, et al [1999] and Morgenstern LB, Frankowski RF, Shedden P, Pasteur W, Grotta JC; Surgical treatment for intracerebral hemorrhage (STICH), [1998] are 2 pilot studies suggested a benefit with early surgery (<12 hours) but were limited by small numbers.
    • Morgenstern and colleagues[2001] showed that ultra-early surgery (that is, 4 hours after ICH) is associated with increased re-hemorrhage and mortality rates
    • A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours) was stopped after interim analysis because of an increased rate of rebleeding.2
    2 Neurosurg Focus 15 (4):Article 2, 2003, Update on management of intracerebral hemorrhage, NADER POURATIAN, M.D., PH.D., NEAL F. KASSELL, M.D., AND AARON S. DUMONT, M.D.
  • 50. Patient’s selection
    • Significant consideration for surgical intervention is given in cases involving younger patients (that is, those < 60 years of age) with superficial hemorrhages (particularly in the non-dominant hemisphere) in whom neurological status deteriorates after an initially good presentation 2
    • Patients with relatively normal consciousness (GCS Scores 13–15 ) rarely require surgery, whereas deeply comatose patients (GCS Scores 3–5 ) rarely benefit from surgery. 4
    • Surgery is therefore usually considered to have the most potential benefit for the group of patients with GCS scores between 6 and 12 or in patients with deteriorating status 4
    2 Neurosurg Focus 15 (4):Article 2, 2003, Update on management of intracerebral hemorrhage, NADER POURATIAN, M.D., PH.D., NEAL F. KASSELL, M.D., AND AARON S. DUMONT, M.D. 4 Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D
  • 51. Patient’s selection
    • There is a neurosurgical bias toward more aggressive surgery for nondominant hemispheric hemorrhages, although the authors of outcome studies have indicated that despite language disability associated with dominant hemispheric lesions, functional outcome is not necessarily worse. 4
    • Standard craniotomy for primary brainstem or thalamic hemorrhages has been all but abandoned because of poor outcomes 4
    • Apparently successful cases of stereotactic aspiration of pontine hematomas have been reported, but the effect on prognosis remains unproven. 4
    • Kanaya and Kuroda [1992] recommended surgical treatment if the hematoma volume was larger than 30 ml and the level of consciousness was somnolent to semicomatose.
    4 Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D
  • 52. Summary of Guidelines for Removal of ICH American Heart Association : Guidelines for the Management of Spontaneous Intracerebral Hemorrhage, 1998 Best therapy unclear Young patients with a moderate or large lobar hemorrhage who are clinically deteriorating (levels of evidence II through V, grade B recommendation). 3. ICH associated with a structural lesion such as an aneurysm, arteriovenous malformation, or cavernous angioma may be removed if the patient has a chance for a good outcome and the structural vascular lesion is surgically accessible (levels of evidence III through V, grade C recommendation). 2. Patients with cerebellar hemorrhage >3 cm who are neurologically deteriorating or who have brain stem compression and hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible (levels of evidence III through V, grade C recommendation). 1. Surgical candidates Patients with a GCS score  4 (levels of evidence II through V, grade B recommendation). However, patients with a GCS score  4 who have a cerebellar hemorrhage with brain stem compression may still be candidates for lifesaving surgery in certain clinical situations. 2. Patients with small hemorrhages (<10 cm 3 ) or minimal neurological deficits (levels of evidence II through V, grade B recommendation). 1. Nonsurgical candidates
  • 53. Surgical Techniques
    • In 1903, Cushing first removed an intracerebral hematoma by craniotomy
    • However operative mortality are high, ranging from 20-90%
    • Because of this, various less invasive methods of removal are practised like simple aspiration, stereotactic aspiration, fibrinolytic treatment, mechanically assisted aspiration, and endoscopy.
    • In particular circumstances, some of these techniques may be more efficacious for deep putaminal or thalamic hemorrhages.
    • Others are beneficial for subcortical hematomas.
    10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768
  • 54. Surgical Techniques
    • The optimal surgical technique for hematoma evacuation is not agreed upon , although craniotomy remains the most common. 4
    • Traditional stereotaxy or frameless navigational systems, as well as intraoperative ultrasonographic guidance, allow more precise clot localization and minimization of injury to normal brain 4
    • Compared with craniotomy, minimally invasive techniques such as stereotactic or endoscopic clot evacuation may offer the potential for a reduced incidence of surgery-related complications and improved efficacy, but this has yet to be proven. 4
    4 Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D.
  • 55. Craniotomy
    • The most widely used surgical intervention in ICH is craniotomy and evacuation of the gross clot.
    • This is a relatively invasive procedure associated with additional risks by subjecting patients to surgery, potential brain manipulation, and anesthesia.
    • For putaminal hematoma, three general approaches have been used, ie transtemporal, transfrontal and transsylvian , with preferred transcisternal-transsylvian-transinsular approach.
    • Operating microscope is used routinely with bipolar coagulation, and graduated sucker.
  • 56. Craniotomy
    • Avoid usage of self-retaining retractors as steady retraction is deleterious to brain parenchymal.
    • The center of hematoma is removed first with the remaining marginal clot then collapses and can likewise be evacuated.
    • Particular attention to bleeding points and possible subtle pathologic findings such as small tumours, cryptic AVMs and carvenous angiomas
    • All tissue is sent for histologic analysis
    • Hemostasis is ensured by elevating systolic pressure temporarily to identify potential rebleeding sites.
    10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768
  • 57. Craniotomy
    • For large hematomas, transcortical approaches is evocated.
    • Transtemporal approach is used if hematomas significantly extends into the temporal lobe
    • The general surgical principles for evacuating hematomas at other locations, is corticotomies are placed near the epicanter of the ICH , their length is minimized, eloquent tissue is avoided.
    • For infratentorial hematomas, a suboccipita l craniotomy is standard, with paramedian incision, craniotomy rather craniectomy, and a ventriculostomy if hydrocephalus.
    10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768
  • 58. Burr Hole Aspiration
    • Unpredictable consistency of hematomas makes aspiration difficult.
    • Experiementally, within one hour of clot genesis, 80% of the clot becomes dense fibrous tissue.
    • There is also a propensity to rebleed, which makes the lack of visualization risker.
    • Niizuma et al (1989) study the result of stereotactic aspiration in 175 patients with putaminal hemorrhage, noted 75% had more than 50% of the clot removed and 7.4% had post-operative bleeding.
    • The low effectiveness and high rates of recurrence are major limitation.
    10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768
  • 59. Stereotactic Aspiration
    • First used by Benes and coworkers in 1965 with limited success and only in 1978, Backlund and Von Holst performed first successful stereotactic aspiration of an acute hemorrhage.
    • It has favourable outcome than craniotomy in deep-seated lesions .
    • However, lack of direct visualization and the risk of rebleeding may limit this technique’s utility especially during the hyperacute phase of hemorrhage.
  • 60. Stereotactic Aspiration and Clot Lysis
    • In 1985, Niizuma et al reported a CT-guided technique of hematoma aspiration and lysis using urokinase .
    • Fibrinolysis is used to fascilitate clot dissolution by activating plasminogen, which dissolves fibrin.
    • Localization by direct-image projection on CT scanner with a radiopaque marker has approximately 5mm error compared to stereotaxy.
    • After localization, 3-4mm silicone tube is passed into the clot and hematoma is aspirated with a syringe repeatedly until no more clot is removed.
    • Then a Dandy ventricular catheter is placed into the hematoma bed, and urokinase ( 6000 U in 3 ml ) is infused, repeated two to four times a day in 1 to 6 days until CT documents clot ressolution.
  • 61. Stereotactic Aspiration and Clot Lysis
    • Compared to t-PA, urokinase is cheaper, longer half-life and has both fibrinolytic and fibrinogenolytic activity ; dissolves existing clot and inhibit the formation of new clot
    • Additional risk is rebleeding .
    • Infectious complications of catheter placement and fibrinolysis vary between 0 and 5%. 4
    • Findlay JM, Grace MG, Weir BK, Neurosurgery; [1993] found that thrombolytic agents have also been successfully used for hemorrhage in the ventricular system
    4 Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D
  • 62. Stereotactic Aspiration and Clot Lysis
    • Naff et al . [Neurosurgery, 2004, Class I] randomized 48 patients with spontaneous IVH to receive placebo or 3 mg TPA injected every 12 hours into the ventricle. Clot resolution was faster in the TPA group , and there was a trend toward lower mortality , although bleeding complications were greater in patients receiving TPA
    • Lee et al . [ Hong Kong Med J 2003 , Class III] reported on 29 patients with IVH treated with intraventricular streptokinase or urokinase, and found that blood could be removed safely (infection rate 3%, no bleeding) and effectively (shunt rate, 24%).
  • 63. Neuroendoscpic Techniques
    • Endoscopy has not been used extensively to treat ICH
    • This minimally invasive techniques designed to decrease hematoma size while limiting surgical trauma.
    • In a study with 6 mm diameter neuroendoscope which was placed through a burr hole and guided by intraoperative ultrasonography. The procedure was associated with good outcome where evacuation more than 50% in all patients with 45% patients with more than 70% clot evacuated. There were no differences in outcome for putaminal or thalamic hemorrhage.
    10 Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768
  • 64. Neuroendoscpic Techniques
    • Auer and colleagues (1989)found of all p;atients whom underwent burr hole, neuroendoscopic navigation, and aspiration of hematoma, those benefit of surgery with respect to QOL was limited to patients with lobar hematomas and those younger than 60 years of age.
    • Benefit may in fact be due to the reduced stress provided by this less invasive surgical procedure, with the persistent benefit of reducing clot volume.
    • Longatti PL, et al in review of 13 patients having endoscopic removal of IVH at one institution during 7 years reported safe and successful removal of blood with favorable outcome in 62% [ Stroke 2004, Class III].
  • 65.
    • Endoscopic Aspiration for Supratentorial ICH
    • Auer LM, Deinsberger W, Neiderkorn K, et al. Endoscopic surgery versus medial treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg. 1989; 70: 530-535
    • Inclusion Criteria: Patients with CT confirmed supratentiorial ICH > 10 cc and < 48 hours from time of onset with altered level of consciousness.
      • 50 patients surgical group
      • 50 patients medical group
    • Treatment: Endoscopic aspiration of clot
    • Outcome: Mortality and disability at 6 months
    • Results:
    Odds Ratio of Death and Dependency: 0.46 (0.20-1.04) surgery better 74% 58% Poor Outcome 70% 42% Mortality Medical Surgical
  • 66. Ventriculostomy
    • Comatose patients in whom neurological status is severely impaired at baseline (GCS score < 9), ICP monitoring , with the aid of either a fiberoptic intraparenchymal monitor or ventriculostomy, may be considered.
    • The advantage of the ventriculostomy is that it can also be used as a therapeutic means of reducing ICP.
    • Adams RE, Diringer MN, Neurology. [1998] study the response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus in 24 patients concluded that external ventricular drains did not improve hydrocephalus, and changes in ventricular volume did not correlate with changes in level of alertness
  • 67. Surgical Evacuation of Cerebellar ICH
    • There seems to be a general consensus regarding the role of surgery in patients with infratentorial hematomas. 4
    • This agreement exists despite that fact that there are no randomized controlled trials evaluating surgical methods in posterior fossa SICH. 4
    • Several series have reported good outcomes associated with surgical evacuation for patients with cerebellar hemorrhages greater than 3 cm , or with brainstem compression and hydrocephalus . 4
    4 Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D.
  • 68. Surgical Evacuation of Cerebellar ICH
    • No evidence from randomized trials of benefits of surgical evacuation in ICH.
    • Evidence mostly in the form of case series.
    • Kobayaski S, Miyata A, Serizawa T, et al. Treatment of cerebellar hemorrhage—surgical or conservative. Stroke. 1990; 21(8) Suppl: I-62.
      • Design: Non-randomized Prospective
      • Patients: 75 patients with cerebellar hemorrhage were studied.
        • 45 treated medically
        • 30 treated with decompressive surgery.
      • Patients with GCS < 13, and hematoma > 40 mm
      • Good outcome occurred 58% with surgery while only 18% with conservative medical therapy
  • 69. Summary of Surgical Treatment Recommendations 4
    • Patients with small hemorrhages or minimal neurological deficit generally do well by undergoing medical treatment alone .
    • Elderly patients in whom the GCS score is less than 5 and those with brainstem hemorrhages also do not typically benefit from surgery
    • Patients with cerebellar hemorrhages greater than 3 cm in whom are symptoms or neurological deterioration have occurred, or in whom brainstem compression and hydrocephalus are present, should undergo evacuation of the clot.
    • Evacuation should be considered in patients with moderate- or large-sized lobar hemorrhages , those with large-sized basal ganglia hemorrhages, and those exhibiting progressive neurological deterioration.
    • Ultra-early removal of the hematoma by localized minimally invasive surgical procedures is promising but unproven .
    4 Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D.
  • 70. ICH Evaluation and Treatment
  • 71. FUTURE DIRECTIONS
    • With the improved understanding of the pathophysiological changes that result in hematoma expansion , the development of cerebral edema , and the identity of hemoglobin degradation neurotoxins will lead to more focused pharmacological treatments.
    • Mayer SA [2003] has suggested there may be a role for ultra-early hemostatic therapy with recombinant factor VIIa to prevent further hematoma expansion.
    • Best medical management has yet to be defined and may include future treatments of blood pressure and hypothermia, tight glucose control, and selected use of glucocorticoids.
    • Results from the STICH have provided important information about the utility of surgical evacuation of ICH but do not address questions about the timing, approach, and technique of other procedures.
  • 72. FUTURE DIRECTIONS -Stem cell therapy
    • After the clot is removed, there is possibility of improving functional outcome by using stem cells to restore the damaged cerebral architecture.
    • Transplanted neural human stem cells have been shown to improve functional recovery in an animal model of ICH (Jeong SW, stroke, 2003)
    • Nonaka M, et al. ( Neurol Res 2004), had human neural stem cells were injected intravenously 1 day after experimental ICH in rats. After 2 months, stem cells had migrated to the perihematomal region where they differentiated into neurons and astrocytes . These animals had better motor function compared with control subjects
  • 73. Hemostatic Therapy: Future?
    • The lack of surgery-related benefit may suggest that clot evacuation after hematoma expansion is not beneficial .
    • Hemostatic therapy , however, is intended to stimulate clotting in individuals in whom the coagulation cascade is otherwise normal, to modify the evolution of the hematoma
    • Much attention has been given to factor VIIa , which promotes local hemostasis at sites of vascular injury in patients with and without coagulopathies.
  • 74. Supported by Levels III through V evidence Grade C Supported by Level II evidence Grade B Supported by Level I evidence Grade A Strength of recommendation Data from anecdotal case series Level V Data from nonrandomized cohort studies using historical controls Level IV Data from nonrandomized concurrent cohort studies Level III Data from randomized trials with high false-positive (  ) or high false-negative (ß) errors Level II Data from randomized trials with low false-positive (  ) and low false-negative (ß) errors Level I Level of evidence
  • 75. Thank You