To discuss the management of spontaneous vs traumatic haematomas Current evidence about the management options

1. Management of Traumatic
versus Non-Traumatic
Intracerebral Bleed
Dr. Amit Agrawal, MCh

2.  To discuss the management of spontaneous vs traumatic
haematomas
 Current evidence about the management options
Aim

3. Spontaneous (SICH)
Chronic hypertension (50%)
Trauma (TICH)
Intracerebral haemorrhage
Caplan LR Intracerebral hematomas. In: H Kaufmann, ed. New York: Raven Press, 1992; 34
Wiener H, et al. The management of spontaneous intracerebral haemorrhage. Contemp
Neurosurg 1992; 14: 1-8

4. Intracerebral haemorrhage
 Arteriovenous
malformation
 Rupture of berry aneurysm
 Secondary to infection
 Brain tumor
 Vasculitis
 Hemorrhagic
transformation of prior
cerebral infarction
 Coagulopathies
Caplan LR Intracerebral hematomas. In: H Kaufmann, ed. New York: Raven Press, 1992; 34
Wiener H, et al. The management of spontaneous intracerebral haemorrhage. Contemp Neurosurg
1992; 14: 1-8

5. Locations
SICH
 Basal ganglia 65%
 Subcortical white
matter 15%
 Cerebellar 10%
 Pontine 10%
TICH (n=45)
 Frontal-18
 Temporal-17
 Parietooccipital-10
Togha M, et al. Factors associated with in-hospital mortality following intracerebral hemorrhage: a
three-year study in Tehran, Iran. BMC Neurology 2004, 4:9 .
Wiener H, Cooper P. The management of spontaneous intracerebral haemorrhage. Contemp
Neurosurg 1992; 14: 1-8.
Andrews BT, et al. The effect of intracerebral hematoma location on the risk of brain-stem
compression and on clinical outcome. J Neurosurg 1988;69(4):518–22.

6. Investigations
 Complete blood count
 Prothrombin time
 Activated partial
thromboplastin time
 Electrolytes
 Electrocardiography
 Chest x-ray
 Computed tomography
(CT)
 Initial primary key
investigation
 MRI with MRA
 Cerebral angiography

7. CT MRI/M
RA
Size and location √ √
Hydrocephalus √ √
Hemorrhagic vs. ischemic stroke √ √
Ventricular extension √ √
Impaired consciousness, hemodynamic
compromise, vomiting, or agitation
√ X
Structural abnormalities i.e. aneurysms,
AVM, brain tumors
√ √√
Time course of brain hemorrhage X √√
Imaging (SICH/TICH)

8. Contrast CT Angiography
Young patient (< 40 years) √ √
Who do not have a specific cause for
hemorrhage
√ √
Atypical appearance/location of the
clot
√ √
Suspicion of an aneurysmal bleed
(Sylvian or interhemispheric fissures)
√ √
Patients with IVH plus ICH √ √
Additional investigations
Bakar IA, et al. Diagnostic Cerebral Angiography in Spontaneous Intracranial Haemorrhage: A Guide for
Developing Countries. Asian J Surg 2005;28(1):1–6.
Hino A, et al. Value of Repeat Angiography in Patients With Spontaneous Subcortical Hemorrhage.
Stroke. 1998;29:2517-2521.
Zhu XL, et al. Spontaneous Intracranial Hemorrhage: Which Patients Need Diagnostic Cerebral
Angiography? A Prospective Study of 206 Cases and Review of the Literature Stroke. 1997;28:1406-
1409.

12. SICH TICH
Airway, breathing, and circulation √ √
Detection of focal neurological
deficits
√ √
Detecting any signs of external
trauma
√ √
Stability of vital functions prior to
scanning
√ √
Emergency management

13. SICH TICH
Fluid resuscitation (Euvolemia) √ √
Electrolytes √ √
Acidosis and alkalosis √ √
Control of body temperature √ √
Prevention of Seizures √ √
Correct coagulation abnormalities √ √
Emergency management contd.
• Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA: The
role of secondary brain injury in determining outcome from severe head injury. J Trauma 34: 216–222, 1993
• The Japanese Association for The Surgery of Trauma: [Japan Advanced Trauma Evaluation and Care, ed 2]. Tokyo,
Herusu Shuppan, 2004, pp 1–21 (Jpn)
• Kokoska ER, Smith GS, Pittman T, Weber TR: Early hypotension worsens neurological outcome in pediatric patients
with moderately severe head trauma. J Pediatr Surg 33: 333–338, 1998
• Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J: The deleterious effects of intraoperative
hypotension on outcome in patients with severe head injuries. J Trauma 33: 403–407, 1992

14.  Steroid versus placebo treatment
 Hemodilution versus best medical therapy
 Glycerol versus placebo
Medical Management (SICH)
Broderick JP, et al. Spontaneous intracerebral hemorrhage. N Engl J Med. 2001;344: 1450–
1460.
Poungvarin N, et al. Effects of dexamethasone in primary supratentorial intracerebral
hemorrhage. N Engl J Med. 1987; 316:1229–1233.
YL Yu, et al. Treatment of acute cerebral hemorrhage with intravenous glycerol. A double-
blind, placebo-controlled, randomized trial. Stroke 1992;23;967-971.

15.  High BP- Subsequent death or dependency
 Blood pressure reduction
 Optimal level is based on individual factors
 Decrease the risk of ongoing bleeding from ruptured
small arteries and arterioles
 Overaggressive treatment may decrease cerebral
perfusion pressure
 Blood pressure reduction of 20%
Blood Pressure Management (SICH)
Willmot M, et al. High Blood Pressure in Acute Stroke and Subsequent OutcomeA Systematic
Review. Hypertension. 2004;43:18-24.
Kaneko T, et al. Lower limit of blood pressure in treatment of acute hypertensive intracranial
hemorrhage (AHCH). J Cereb Blood Flow Metab. 1983;3(suppl):S51–S52.
Bhuvaneswari K et al. Relation Between Blood Pressure and Outcome in Intracerebral Hemorrhage.
Stroke. 1995;26:21-24.

16.  Management of ICP
 Optimal head position
 Osmotherapy (Mannitol vs 3% saline)
 Controlled hyperventilation
 Barbiturate coma
 ICP monitoring if required
Medical Management (SICH/TICH)

17.  Alcohol consumption
 Anticoagulant treatment
 Aspirin use
 Use of amphetamines or cocaine
Control of risk factors (SICH)
Juvela S, et al. Risk Factors for Spontaneous Intracerebral Hemorrhage Stroke.
1995;26:1558-1564.
Donahue RP, et al. Alcohol and hemorrhagic stroke: the Honolulu Heart Program. JAMA.
1986;255:2311-2314.
Deykin D, et al. Ethanol potentiation of aspirin-induced prolongation of the bleeding time.
N Engl J Med. 1982;306:852-854.

18. However, no convincing evidence of
the benefit of any particular medical
treatment
 Gregson BA, et al. International Variations in Surgical Practice for Spontaneous
Intracerebral Hemorrhage. Stroke. 2003;34:2593-2598.
 Fernandes HM, et al. Surgery in intracerebral hemorrhage: the uncertainty continues.
Stroke. 2000;31: 2511–2516.
 Zuccarello M, et al. Early Surgical Treatment for Supratentorial Intracerebral
Hemorrhage A Randomized Feasibility Study. Stroke. 1999;30:1833-1839.
Medical Management (SICH/TICH)

19. SICH TICH
Safe and thorough clot evacuation √ √
Maximal preservation of neurological
function
√ √
Should minimize the secondary brain damage √ √
Should be performed before irreversible
brainstem damage or generalized brain
damage
√ √
Diagnosis and emergent treatment of severe
systemic injuries and ongoing hemorrhagic
shock
- √
Surgery-objectives
American College of Surgeons Committee on Trauma: Initial assessment and management, in:
Advanced Trauma Life Support for Doctors, Instructors Course Manual. Chicago, American College of
Surgeons, 1997, pp 21–46
The Japan Society of Neurotraumatology: [JSNT Guideline, ed 2]. Tokyo, Igaku Shoin, 2007, pp 1–21
(Jpn)

20.  Reduces hematoma volume and mass effect
 Lowers the intracranial pressure
 Improves perfusion in the affected hemisphere
 Remove the source of toxic products i.e.
haematoma and chances of edema formation
Why Clot removal? (SICH/TICH)
Lopez Valdes E, et al. Time window for clinical effectiveness of mass evacuation in a rat balloon model mimicking an
intraparenchymatous hematoma. J Neurol Sci. 2000;174:40–46.
Siddique MS, et al. Changes in cerebral blood flow as measured by HMPAO SPECT in patients following spontaneous
intracerebral haemorrhage. Acta Neurochir Suppl. 2000;76:517–520.
Zazulia AR, et al. Hypoperfusion without ischemia surrounding acute intracerebral hemorrhage. J Cereb Blood Flow
Metab. 2001;21: 804–810.
Yang GY, et al. The effects of blood or plasma clot on brain edema in the rat with intracerebral hemorrhage. Acta
Neurochir Suppl (Wien). 1994;60:555–557.

21. Surgery-Indications
SICH TICH
Haematoma volume 20—80 ml >25 ml
Lobar/superficial haematomas √ √
Younger patients with worse or
deteriorating GCS scores √ √
Midline shift/raised ICP √ √
The presence of lateralizing signs √ √
The wishes of the patient/family √ √
Barbara A. et al. International Variations in Surgical Practice for Spontaneous Intracerebral Hemorrhage. Stroke.
2003;34:2593-2598.
Tsementzis SA. Surgical management of intracerebral hematomas. Neurosurgery. 1985;16:562–572.
Siddique MS, et al. Surgical treatment of intracerebral haemorrhage
Fernandes HM, et al. Spontaneous intracerebral haemorrhage: a surgical dilemma. Br Neurosurg 1999; 13: 389-94
Mathiesen T, et al. Traumatic intracerebral lesions without extracerebral haematoma in 218 patients. Acta Neurochir
(Wien). 1995;137(3-4):155-63.

22.  Early hematoma evacuation (within 3 to 6 hours of
symptom onset)
 May reduce perihematoma ischemia
 Toxic effects of blood components
 May contain hemorrhage progression
Intervention-Timing
Morgenstern LB, et al. Surgical treatment for intracerebral hemorrhage (STICH)A single-center,
randomized clinical trial. NEUROLOGY 1998;51: 1359-1363.
Zuccarello M, et al. Early Surgical Treatment for Supratentorial Intracerebral Hemorrhage A
Randomized Feasibility Study. Stroke. 1999;30:1833-1839.
Nasser JA, et al. Stereotactic fibrinolysis of spontaneous intracerebral hematoma using infusion of
recombinant tissue plasminogen activator. Arq Neuropsiquiatr 2002;60(2-B):362-366.

23.  Recombinant activated factor VIIa
 Within 3 to 4 hours of onset
 Promotes local hemostasis and potentially arrest ongoing
bleeding
 Minimize hematoma growth
 Did not reduce the rate of death or severe disability
Ultra-early hemostatic therapy
Mayer SA. Ultra-Early Hemostatic Therapy for Intracerebral Hemorrhage. Stroke. 2003;34:224-229.
Mayer SA , et al. Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral
Hemorrhage. N Engl J Med 2008;358:2127-37.

24. SICH TICH
Conventional craniotomy √ √√
Ultrasound-guided endoscopic clot
removal
√ √
Stereotactic removal √ √
Stereotactic infusion of tissue plasminogen
activator (rtPA), Urokinase
√ √
Surgery-options
Auer LM, et al: Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomised
study. J Neurosurg, 1989; 70: 530–35
Nakano T, et al: Neuroendoscopic surgery for intracerebral haemorrhage. Comparison with traditional therapies.
Minim Invas Neurosurg, 2003; 46: 278–83
Nasser JA et al. Stereotactic fibrinolysis of spontaneous intracerebral hematoma using infusion of recombinant tissue
plasminogen activator. Arq Neuropsiquiatr 2002;60(2-B):362-366.
Marquardt G, et al: Manual stereotactic aspiration of spontaneous deep-seated intracerebral haematomas in non-
comatose patients. Br J Neurosurg, 2001; 15: 126–31..

25.  Standard approach
 Adequate exposure and more complete clot
removal decreasing elevated ICP and local
pressure effects
 Necessary where a progression in brain swelling
is expected
 Howevr, no unequivocal evidence that it
reduces mortality
Classical open craniotomy
Prasad K, et al. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane
Database Syst Rev. 2000;2:CD000200.

26.  Prioritize the management of systemic injuries
 Balance the necessity of controlling abdominal or thoracic
hemorrhage against the potential risk of delaying
craniotomy
Management (TICH)
The Japan Society of Neurotraumatology: [JSNT Guideline, ed 2]. Tokyo, Igaku Shoin, 2007, pp 1–21 (Jpn)
Thomason M, et al. Head CT scanning versus urgent exploration in the hypotensive blunt trauma
patient. J Trauma 1993;34: 40–45.
Fukai J, et al. Timing of Craniotomy in a Patient With Multiple Trauma Including Head Injury—Case
Report— Neurol Med Chir (Tokyo) 2009;49, 22-25.

27.  Whenever there is a doubt-craniotomy
 Burst temporal lobe-craniotomy
 Temporal lobe Hematomas with an absent or compressed
cistern –no policy of wait and watch
Management (TICH)
Fernandes YBG et al. Minimally invasive approach to traumatic intracerebral
hematomas

28. Lack of compensatory space to accommodate temporal lobe
swelling with greater risk for brainstem compression
Lobato RD, et al. Outcome from severe head injury related to the type of intracranial lesion. A
computerized tomography study. J Neurosurg 1983;59(5):762–74.
Andrews BT, et al. The effect of intracerebral hematoma location on the risk of brain-stem compression
and on clinical outcome. J Neurosurg 1988;69(4):518–22.
Kumchev Y, et al. Traumatic intracerebral hematomas–diagnostic and therapeutic problem. Folio Med
(Plovdiv) 1998;4091:52–7.

29. Craniotomy Minimally invasive
Reduction in the volume ++ +
Jellylike hyper-acute clots √ X
Tissue damage ++ +
Small deep hematomas X √
Intra-ventricular thrombolytic
therapy
X √
Expensive equipment X √
Craniotomy vs minimally invasive
approach
Zuccarello M, et al. Early Surgical Treatment for Supratentorial Intracerebral Hemorrhage A Randomized Feasibility
Study. Stroke. 1999;30:1833-1839.
Auer LM, et al. Does acute endoscopic evacuation improve the outcome of patients with spontaneous intracerebral
hemorrhage? Eur Neurol. 1985;24: 254–261.
Montes JM, et al. Stereotactic computed-tomographic aspiration and thrombolysis of intracerebral hematoma:
protocol and preliminary experience. Stroke. 2000;31:834 – 840.

30.  However, there is not enough evidence to suggest the
superiority of one method over another in terms of patient
outcome

31.  45 year male
 Uncontrolled hypertension
 GCS-E1V1M1
 Pupils B/L fixed
Case 1

32.  45 year male
 Road traffic accident
 Chronic alcoholic
 GCS-E1V1M1
 Pupils B/L fixed
Case 2

33. No intervention

34.  35 year male
 Uncontrolled hypertension
 GCS-E2V3M5
 Pupils B/L reacting
Case 3

35. Surgical evacuation

36. Case 4

37.  50 year male
 Uncontrolled hypertension
 GCS-E3V3M5
 Pupils B/L reacting
Case 5

38.  55 year male
 Road traffic accident
 No hypertension
 GCS-E3V4M5
 Pupils B/L reacting
Case 6

39. More cases

40. Conservative

41. SICH TICH
The severity of bleeding √ √
The level of consciousness on admission √ √
Cortical location √ √
Age younger patients √ √
Intraventricular spread of the bleeding √ √
Hydrocephalus √ √
First-day MAP √ -
Low fibrinogen levels √ -
Prognosis
Broderick JP, et al. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg.
1993;78:188-191.
Fogelholm R, et al. Prognostic Value and Determinants of First-Day Mean Arterial Pressure in Spontaneous Supratentorial
Intracerebral Hemorrhage. Stroke. 1997;28:1396-1400.
Togha M, et al. Factors associated with in-hospital mortality following intracerebral hemorrhage: a three-year study in
Tehran, Iran. BMC Neurology 2004, 4:9 .

42. Prognosis
SICH TICH
Associated subdural haematomas - √
Temporal localization of hematoma - √
Multipl/bilateral contusions - √
Inadequate resuscitation for
extracranial bleeding
- √
Djurovic BM, et al. [Neurosurgical treatment of spontaneous and traumatic intracerebral hematomas] [Article in Serbian] Acta Chir
Iugosl. 2008;55(2):123-7.
Mushkudiani NA, et al. Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. J
Neurotraum 2007;24(2):259–69.
MRC CRASH trial collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of
international patients. BMJ 2008;23,336(7641):425–9.

43.  Israel’s Prime Minister- public debate-
extraordinary measures (surgical treatment)
were undertaken only because of the celebrity
of the patient
 When a patient is deteriorating rapidly, failure
to remove the clot could even lead to charges of
negligence.
Issues
Segal R, et al. Spontaneous Intracerebral Hemorrhage: To Operate or Not To Operate, That’s
the Question. IMAJ2006;8:815–818

44.  Despite of improvements in medical and neurosurgical
measures, ICH remains a serious disease
 Although guidelines are helpful in patient management, but
also leave questions to conduct well-designed and well-
executed future studies
Conclusion