This powerpoint gives insight into the management of haemorrhagic stroke.

1. Evidence Based management of Haemorrhagic
Stroke
Presenter: Dr Pradeep Mandal( MD- internal medicine- 2016 batch)
Moderator: Dr Bhupendra Shah( Assistant Professor)

2. Epidemiology:
1. Stroke – 3rd leading cause of
death
2. Leading cause of adult
disability
MT Mullen, J S Mc Kinney and S E Kasner; Blood pressure management in acute stroke Journal of Human Hypertension (2009) 23, 559–569 (2009)

3. Incidence of Intracranial haemmorrhage:
• 10-20% of all strokes
• Incidence increases with age
Hemorrhagic stroke in Nepal: 42.38%
Sang Joon An, Tae Jung Kim, and Byung-Woo Yoon;Epidemiology, Risk Factors, and Clinical Features of Intracerebral
Hemorrhage: An Update, J Stroke. 2017 Jan; 19(1): 3–10.
ICH leads to higher mortality and more severe disability compared to Ischemic stroke
Shrestha A, Shah DB, Koirala SR, Adhikari KR, Sapkota S, Regmi PR;Retrospective Analysis of Stroke and Its Risk Factors at Bir Hospital.
Volume 11│Number 2│Jul-Dec 2011

4. Prognosis of Hemorrhagic Stroke
Case Fatality rate:
-40% at 1 month
-54% at 1 year
High Income countries: 25-30%
Low- middle income countries: 30- 48%
Deep haemorrhage 51%
Lobar haemorrhage 57%
Cerebellar haemorrhage 42%
Brain stem haemorrhage 65%
Death at 1 year for ICH:
Functionally independent at 6 months: 20%
AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults 2007

5. Clinical Vignette
• A 74- old female presented at Emergency presented with
- Right sided weakness: 3 hours
- Altered sensorium: 3 Hours
On Examination:
GCS score: E3V2M5
BP- 190/ 110 mmHg
Provisional diagnosis :Stroke

7. Patient attendant asked for the prognosis?
• How to answer it?

8. Prognosis scale:
Intracerebral Hemorrhage Scale Points (Score range: 0 to 6)
GCS
3 - 4 points 2
5 -12 points 1
13 – 15 points 0
Volume of ICH on CT ( cm3)
≥ 30 cm 1
< 30cm 0
IVH
Present 1
Absent 0
Hemorrhage infratentorial in location
Yes 1
No 0
Age
80 years or older 1
< 80 years 0
30 day mortality at total points
5
4
3
2
1
Percentage
100%
97%
72%
26%
13%
ICH scoring of our patient:
1+1+1+0+0=3

9. What next?
• Should we refer her for neurosurgical intervention or managed
conservatively?

10. STICH I trial

12. Medical Versus Surgical Management:
ProfA DavidMendelow et al.Early surgery versus initial conservative treatment in patients with spontaneous supratentorial
lobar intracerebral haematomas (STICH II): a randomised trial,The Lancet; Volume 382, Issue 9890, 3–9 August 2013, Pages
397-408
Surgery: 307 patients
Conservative management: 294 patients
Treatment: Early evacuation of Hematoma
Outcome: Favourable or unfavourable outcome on 8 point extended
Glasgow outcome scale and Mortality at 6 months
Surgery Medical
Unfavourable outcome 59% 62%
Mortality 18% 24%

13. In our patient,Evidence favours
• Medical management
• Patient party don’t want take the patient to another center
Possible challenges felt: Ventriculostomy

14. Emergency management?

15. Do we need to manage hypertension?

16. Why we need to control Blood pressure?
• >33% increase in size of hematoma in 24 hours

17. What is the Blood pressure target?

19. How to reduce the Blood pressure?
SBP MAP Intervention
>200 mmHg >130 mmHg Continuous IV infusion
>180 mmHg >130 mmHg + raised ICT Need Cerebral pressure
monitoring > 60 mmHg
>180 mmHg >130 mmHg Intermittent IV medication
Target BP: <180 mmHg

20. What about the raised Intracranial
tension?
External ventricular drain
Indication:
1. GCS ≤ 8
2. Significant Intraventricular haemorrhage
3. Hydrocephalus
4. Evidence of transtentorial herniation
Cyrus K Dastur, Wengui Yu; Current management of spontaneous intracerebral haemorrhage; Review

22. Seizures:
Acute seizures:
IV Lorazepam (0.05 to 0.1 mg/kg)
Loading phenytoin or fosphenytoin
(20mg/Kg)
30 day risk:
convulsive seizure: 8%
status epilepticus: 1-2%
Prophylaxis: No beneficial effects
Risk after ICH: 16% in 1 week
Most Important risk factor: Lobar ICH with cortical involvement
Spontaneous Intracerebral Hemorrhage: Management J Stroke. 2017 Jan; 19(1): 28–39.

23. Anticoagulation associated bleed
12-20% of patients presenting with ICH taking oral anticoagulants
Warfarin increases risk of ICH by 5-10 fold
76% of patients die or become dependent
Sang Joon An, Tae Jung Kim, and Byung-Woo Yoon;Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage:
An Update; J Stroke. 2017 Jan; 19(1): 3–10.

24. Warfarin:
1. Stop Vitamin K
Antagonist
2. Vitamin K 5-10mg IV in 1st hours
+
Prothrombin complex concentrates
2-4 units FFP
rFVIIa (10-90mcg/Kg)
If repeat INR>1.4 after 15-60min
Cyrus K Dastur, Wengui Yu; Current management of spontaneous intracerebral haemorrhage; Review

25. •Platelet dysfunction or thrombocytopenia:
Platelet Transfusion 6 units
and/or
Desmopressin 0.3mcg/Kg single dose

26. Tranexamic acid in haemorrhagic stroke:
Effective in Subarachnoid haemorrhage
Tranexamic acid had nonsignificant reduction in mortality in traumatic
ICH (CRASH-2 trial)

27. Role of Factor rFVIIa:
• Hematoma growth occurs in 70% of patients within 3 hours
• Mechanism: Directly activates factor X
• Previous study: rFVIIa reduces growth of ICH and improves survival
and functional outcome at 90 days

29. Glucose Management:
• Hyperglycaemia control
• Avoid tight glucose control (80-110mg/dl)
• Target Glucose level:100-150 mg/dl
• Regular glucose monitoring

30. Deep Vein Thrombosis Prophylaxis:
• Risk of symptomatic DVT: 1-5%
• Risk of symptomatic Pulmonary Embolism: 0.5 – 2%
• Prophylaxis:
• 1. Intermittent pneumatic compression
• 2. Graduated compression stockings
• 3. Subcutaneous Unfractionated heparin or LMWH
Should be started within 48 hours of admission in stable hematomas
Use IVC filter if systemic anticoagulant is contraindicated
Spontaneous Intracerebral Hemorrhage: Management J Stroke. 2017 Jan; 19(1): 28–39.

31. Surgical Management:
Indications:
Situation Surgery
Cerebellar haemorrhage + neurological
deterioration + brainstem compression
or hydrocephalus
Hematoma Evacuation
Supratentorial haemorrhage +
neurological deterioration
Hematoma Evacuation
Supratentorial haemorrhage + GCS score
< 8, midline shift and large hematomas,
medically intractable ICP
Decompressive craniectomy
Hydrocephalus +/- IVH Ventricular drainage

32. Surgical Management:
•Supratentorial Hemorrhage:
1. Hematoma Evacuation: No benefit
(STITCH Trial and STITCH II trial)
2. Decompressive Craniectomy:
MISTIE Trial II showed
reduction in
perihematomal edema
in hematoma
evacuation group
Role of minimally invasive surgical evacuation
Vs
Spontaneous Intracerebral Hemorrhage: Management J Stroke. 2017 Jan; 19(1): 28–39.

33. Infratentorial haemorrhage:
Hematoma Evacuation: Better outcome
1. Cerebellar Hemorrhage:
2. Brainstem Hemorrhage: Usually managed conservatively
Intraventricular haemorrhage:
Treatment: Ventricular catheter insertion with thrombolytic agent (rtPA)

35. Take Home Message:
• No need to transfer every patient except some patient who need
surgical intervention
• Medically managed by lowering Blood pressure, seizure control, DVT
prophylaxis and physiotherapy

36. Harrison‘s Principles of Internal Medicine, 19th Edition
MT Mullen, J S Mc Kinney and S E Kasner; Blood pressure management in acute
stroke Journal of Human Hypertension (2009) 23, 559–569 (2009)
Sang Joon An, Tae Jung Kim, and Byung-Woo Yoon;Epidemiology, Risk Factors,
and Clinical Features of Intracerebral Hemorrhage: An Update, J Stroke. 2017
Jan; 19(1): 3–10.
AHA/ASA Guidelines for the Management of Spontaneous Intracerebral
Hemorrhage in Adults 2007
Prof A David Mendelow et al.Early surgery versus initial conservative treatment
in patients with spontaneous supratentorial lobar intracerebral haematomas
(STICH II): a randomised trial,The Lancet; Volume 382, Issue 9890, 3–9 August
2013, Pages 397-408
Spontaneous Intracerebral Hemorrhage: Management J Stroke. 2017 Jan; 19(1):
28–39.

37. Thank You