Outline of medical and surgical management of intracerebra hemorrhage largely based on AHA guidelines

1. Spontaneous Intracerebral Hematoma
Dhaval Shukla
Prof. & HOD of Neurosurgery
National Institute of Mental Health and Neurosciences
[NIMHANS] Bangalore

2. Epidemiology of Stroke
• Annual incidence 108/100,000 to 172/100,000
• Hemorrhagic
– 11% in Trivandrum to 35% in Kolkata
• Hypertension
• Higher salt intakes
• Females 41%
• One-month case fatality 18% to 42%
– Highest in the studies based in Kolkata (41–42%)
Int J Stroke 2022

3. ICH
• Deadliest form of acute stroke
• Mortality about 30% to 40%
• No or minimal trend toward improvement
– Incidence of ICH increases sharply with age
– More widespread use of anticoagulants

4. Location and Etiology

5. ICH - Locations
Arteriosclerosis Cerebral Amyloid Angiopathy

6. ICH - Risk Factors
Arteriosclerosis
Risk factors
• Hypertension
• Diabetes
• Age
Cerebral Amyloid Angiopathy
Risk factors
• Age
• Apolipoprotein E genotypes
containing the ε2 or ε4
alleles

12. Angiogram
• <70 years of age with lobar ICH
• <45 years of age with deep or posterior fossa ICH
• 45 to 70 years of age with deep or posterior fossa ICH
and the absence of both hypertension and signs of
small vessel disease on imaging
• All patients with ICH with CT or MRI evidence of a
macrovascular lesion
• Patients with primary IVH

13. Indication of CTA

14. Courtsey – Dr. Nadeem, NIMHANS

18. ICH – Different Etiology
Anticoagulant Arteriovenous Malformation

19. Pathophysiology

20. Hematoma Volume Expansion
> 30 ml
unfavorable outcome
> 60 ml & GCS < 8
Mortality > 90%
> 150 mL
immediate death

21. Hematoma Expansion (HE)
Predictors and Risk Factors
• CT scan
– Timing
– NCCT
– CTA
• Hypertension
• Anticoagulants

22. HE – CT timing
ICH
• 15% - 6 and 12 hours
• 6% - 12 and 24 hours
• 0% - 24 hours
IVH
• 21% - >24 hours
Cerebral Oedema
• 48 hours
4 CT scans
Initial < 3 hours
• 6 hours
• 24 hours
• 48 hours

23. Noncontrast computed tomography (NCCT)
markers of risk of HE

24. Computed tomography angiography (CTA)
spot sign marker of risk of HE
2 hours of onset of symptoms

25. Hypertension
• Initiate treatment within 2 hours of ICH
• Target SBP 130 to 150 mm Hg
• Careful titration
• Continuous smooth and sustained control
• Avoid peaks and large variability
• SBP to <130 mm Hg is potentially harmful

27. HE - General Hemostatic Treatments
• Platelet transfusion
– Only for patients scheduled for surgery
– Harmful otherwise
• No role of following
– Desmopressin
– Factor VIIa
– Tranexamic acid

28. Issues in Medical Management

29. Issues in Medical Management

30. Issues in Medical Management

31. Monitoring

32. Surgical Treatment

33. RCT -MIND

34. RCT - ENRICH

35. MIS
• ICH of >20- to 30-mL
• GCS 5–12
– Reduce mortality
– Functional outcomes is uncertain
• Select MIS over craniotomy to improve
functional outcomes
>80% reduction of ICH volume is required
Only 1/3rd patients achieve this target

37. Craniotomy & Evacuation of ICH
• Moderate or greater severity
– Functional outcomes or mortality is uncertain
• Deteriorating
– Lifesaving

38. Decompressive Craniectomy (DC)
Indications
• Coma
• Large hematomas
• Significant midline shift
• Elevated ICP refractory to medical
management
DC with or without hematoma evacuation
may be considered to reduce mortality
Functional outcomes is uncertain

40. Surgery is an Option
Younger

41. Supratentorial ICH without significant
IVH

42. Optimally Invasive Approach

43. Minicraniotomy
Courtsey – Dr. Akshohini Garg, NIMHANS

45. Why surgical ICH trials may have failed?
• The primary injury of hemorrhage is not possible to be
treated with surgery.
• Neurosurgical patients requiring urgent procedures are
difficult to recruit.
• The ideal candidate and the optimal timing of surgery
are essential questions that have not been determined.
• Many clinicians would consider hematoma drainage a
life-saving measure in some situations; therefore,
patients who were considered to benefit from surgery
were not enrolled in these studies.

46. Why surgical ICH trials may have failed?
• Large crossover from medical management to surgical
group. If no patient had crossed over from medical
management to surgical group, the rates of unfavorable
outcome and death with conservative management
would have been higher.
• Problems with study designed, sample size, and number
of excluded patients.
• Slow recruitment due to very restrictive inclusion
protocols.
– A population-based study showed that very small
percentages of ICH patients were eligible for the STICH II
trial, i.e., 9.5% of lobar ICH without IVH and only 3.7% of
all ICH patients

47. Cerebellar hematomas
• Deteriorating neurologically
• Brainstem compression and/or hydrocephalus
• Volume ≥15 ml
Immediate surgical removal of ICH with or without EVD
is recommended to reduce mortality

48. Posterior fossa ICH

49. Out of sight out of mind

50. Out of sight out of mind

51. Outcome Prediction
Neurological Research and Practice 2021

52. Recurrent ICH
• Arteriosclerosis – 1.1%/ year
• CAA - 7.4% year
– lobar location
– older age
– presence, number, and lobar location of microbleeds
– presence of disseminated cortical superficial siderosis
– poorly controlled hypertension 130/80 mm Hg
– presence of apolipoprotein
– E ε2 or ε4 alleles

55. Take Home Message
• ICH is deadly
• In the patient with suspected stroke
– Perform a rapid assessment
– Obtain a glucose and noncontrast head CT
– CTA may be helpful, as can venography in select
patients

56. Take Home Message
• Once ICH is diagnosed on CT, goals are to
– stabilize the patient,
– control BP (rapid control with an IV infusion),
– prevent further injury (avoid elevated ICP,
hypoxia, hypotension, hypoglycemia),
– admit to an appropriate facility
Do surgery immediately for
IVH and Cerebellar Hematoma

57. Further Reading