literature summary of different types of intracranial haemorrhage and their management highlighting relevent or controversial papers

1. Intracranial Haemorrhage
Barbara Stanley FRCA
Consultant Neuroanaesthetist
www.theneurosim.com

2. Where to start??
• Intracranial hemorrhage (MeSH term) + 2010
– 2014 = 4839
• Review articles only = 246
• Each type of bleed – last 5 years on PubMed
www.theneurosim.com

3. Types of Haemorrhage
• EDH – 1 - 4% of TBI up to 15% post mortem series
• SDH – Acute (up to 72hrs) – 30% severe TBI and
chronic (2-3 weeks) 7.35% of 70-79yr olds
• ICH – 24.6/100,000 – 1 month mortality 40%.
Only 12-39% live independently. Best outcomes =
Japan
• SAH – 10-15/100,000 higher Finland/Japan lower
China. 50% die, 30% survivors remain dependent
www.theneurosim.com

4. www.theneurosim.com

5. EDH
• 30 cm3 = Surgical Evacuation
• <30cm3 + <5cm midline shift + < 15mm
thickest part AND GCS > 8 with NO FOCAL
DEFICIT = serial CT + observe in Neurosurgical
unit
– BTF Guidelines http://tbiguidelines.org/glHome.aspx?gl=3
www.theneurosim.com

6. • Extradural haematoma—To evacuate or not?
Revisiting treatment guidelines Z. Zakaria et al.
Clinical Neurology and Neurosurgery 115 (2013)
1201–1205
– 3 cases
– 2 large (>30cm3) EDH’s managed conservatively = good
outcomes
– 1 large EDH surgically evacuated = poor outcome
– Excellent summary of current literature on EDH and
existing controversies
www.theneurosim.com

7. 28yr old. Fall. CT scan showed a large EDH in the right parieto-occipital region with a
MLS of 5mm(Fig. 1a). Small temporal contusions were also noted on the scan. The
blood volume was 90cm3. He was admitted for neurologic observation and
analgesics were administered. After a few hours, his symptoms receded, and 24 h
later he remained well. A repeat CT scan showed no change in the features of the
EDH. www.theneurosim.com

8. www.theneurosim.com
56 man. Fall. GCS 7/15 fixed midsize pupils. 30 cm3 clot overlaying transverse sinus.
Hydrocephalus. EVD and VP shunt. Full recovery

9. www.theneurosim.com
52 man. Collapse. GCS 14/15 then 6/15. 130cm3 Rt EDH clot with 1mm shift
evacuated. Dense Rt hemiplegia with GCS 13/15 outcome = Kernahon’s Notch
phenomenon.

10. Acute SDH
• >10mm thick or >5mm shift = surgical
evacuation regardless of GCS
• <10mm thick + <5mm shift operate if GCS <9
AND/OR:
– GCS drop by 2 between injury + admission
– Pupils fixed dilated
– ICP >20
– BTF Guidelines: http://tbiguidelines.org/glHome.aspx?gl=3
www.theneurosim.com

11. SDH
• Mortality uncomplicated ASDH = 20% but up
to 50% and even 70% in some studies (Taussky et al 2008)
• Why so bad?
www.theneurosim.com
GOS 4 + 5
GOS 3
GOS 1 + 2
anisocore
areactive
anisocore
reactive
isocore
reactive
100%
80%
60%
40%
20%
0%
Pupil
reactivity on
initial
assessment
(Taussky et al
2008)
Age and
initial GCS
also
predict
outcome

12. Decompressive Craniectomy
• Depends on how you class a “favourable”
outcome:
– Ischaemic stroke- improves survival BUT analysis of
European Stroke Trials classed modified Rankin Score
4 as favourable (Vahedi et al Lancet 2007)
– Meta analysis increases chance survival with
unfavourable outcome
– TBI – No evidence increased chance of survival with
favourable or unfavourable outcome – studies are
heterogenous (Honeybul & Ho 2013)
– DECRA – early DC for ICP > 20 for 15mins. Outcomes
worse in surgical arm @6/12
– Also has high morbidity/ complication rate
www.theneurosim.com

13. Chronic SDH
www.theneurosim.com

14. CSDH
• Mortality around 13%
• Craniostomy (Burr holes) 1st line mx +
morbidity higher in craniotomy
• Drain = less recurrence (Weigel et 2003)
• 2 Burr holes better than 1 – less infection +
shorter hospital stay (Smith et al 2012)
• Significant correlation exists between initial
GCS and GOS after burr hole (Amirjamshidi et al 2007)
www.theneurosim.com

15. CSDH > 90yrs
• 2 recent papers:
• Stippler et al 2013. 21 pts >90yrs. 16 (76%) =
surgery (craniotomy or burr hole) 5 were
observed. Surgical group =31% died. 31%
nursing home. 13% rehab. 24% home
• Tabuchia et al 2014. 20 pts >90yrs. 12 (60%)
burr hole under LA – rest conservative.
Surgical group = 0 deaths. 66.7% home
www.theneurosim.com

16. SAH Stroke. 2009;40:0-0
• If it has bled – secure it (Class I, Level of Evidence B).
• Do it early (Class IIa, Level of Evidence B) – and in a centre
where it’s done a lot (Class IIa, Level of Evidence B).
• If it’s amenable to coil or clip – coil it (Class I, Level of
Evidence B) ISAT showed endovascular coiling is associated
with better outcomes at 1 year than surgical clipping if both
surgeon and radiologist equally experienced
• Anaesthetists – minimise hypotension during securing(Class
IIa, Level of Evidence B).
• For Vasospasm – Nimodipine (Class I, Level of Evidence A).
Normovolaemia (Class IIa, Level of Evidence B). Triple H
therapy (Class IIa, Level of Evidence B). Angioplasty or
intraluminal vasodilators (Class IIb, Level of Evidence B).
www.theneurosim.com

17. • Subarachnoid hemorrhage: an update for the
intensivist. A. Coppadoro, G. Citerio. Minerva
Anestesiol 2011;77:74-84
– After five years, relative risk of death is less for patients
who have undergone coiling treatment, but no difference
is demonstrated in the probability of good neurological
status
– Risk of reintervention with coiling is higher than clipping
– Conversely, risk of rebleeding at eight years does not
appear to be dependent on the type of treatment
– Expert Committee of the American Academy of Neurology
supports the use of TCD on the basis that severe spasms
can be identified with fairly high reliability.
– Emerging evidence shows CT perfusion (CTP) as the
imaging technique of choice for early assessment of
vasospasms. Unlike TCD it is predictive of secondary
cerebral infarction
www.theneurosim.com

18. • vasopressor-induced elevation of mean arterial
pressure causes a significant increase in regional
cerebral blood flow and brain tissue oxygenation
whereas volume expansion only slightly increased flow
and reversed the positive effect on tissue oxygenation
• Clazosentan, an endothelin receptor antagonist.
showed a dose-dependent reduction in angiographic
vasospasms in comparison with a placebo in a recent
RCT of 413 patients but is NOT SIGNIFICANT
(CONSCIOUS 2)
• MASH 2 trial magnesium treatment decreased the
occurrence of DCI and poor outcome but MASH 3
(phase 3 trial + metanalysis) showed no reduction in
poor outcome
www.theneurosim.com

19. • Effect of different components of triple-H
therapy on cerebral perfusion in patients with
aneurysmal subarachnoid haemorrhage: a
systematic review. Dankbaar et al. Critical Care
2010, 14:R23
– There is no good evidence from controlled studies
for a positive effect of triple-H or its separate
components on CBF in SAH patients. In
uncontrolled studies, hypertension seems to be
more effective in increasing CBF than
hemodilution or hypervolemia
www.theneurosim.com

20. www.theneurosim.com
• Subarachnoid hemorrhage from intracranial aneurysms
during pregnancy and the puerperium. Kataoka H et al.
Neurol Med Chir (Tokyo). 2013;53(8):549-54
• > 50% IA ruptures occur in third trimester
• Both mother and foetus benefit from surgery –
maternal mortality in surgical group 11% vs 63% in
non-surgical and foetal mortality is 5% vs 27%
• If gestation >28 weeks – c-section and clipping. If not –
clip whilst maintain pregnancy
• If ICP high – clot evac and EVD whilst foetal monitoring.
If foetal distress – suspend ICP procedure and c-section
• Coiling – radiation absorption is low but heparinization
and re-bleed risk is greater – so clipping better – but
not unsafe (Endovascular treatment in pregnancy.
Neurol Med Chir (Tokyo). 2013;53(8):541-8 for an
excellent summary)

21. ICH Stroke.2010;41:2108-2129
• Rapid Imaging (Class I; Level of Evidence: A).
• Control the BP if >>150 = aim for 140 (Class IIa; Level of
Evidence: B).
• Correct their INR (Class I; Level of Evidence: C)
• PCCs have not shown improved outcome compared
with FFP but less side effects so reasonable alternative.
rfVII alone not recommended for OAC reversal
• Monitor + manage in ICU (Class I; Level of Evidence: B).
• Although theoretically attractive, no clear evidence at
present indicates that ultra-early removal of
supratentorial ICH improves functional outcome or
mortality rate. Very early craniotomy may be harmful
due to increased risk of recurrent bleeding (Class III;
Level of Evidence: B)
www.theneurosim.com

22. • Surgery for Intracerebral Hemorrhage Moving Forward
or Making Circles? Flaherty & Beck.
Stroke.2013;44:2953-2954.
• 2 basic rationales for surgical removal of blood after.
ICH.
– to reduce mass effect, to improve intracranial pressure and brain
perfusion and to prevent dangerous compartment shifts and
herniation
– removal of blood products may reduce secondary injury caused by
blood breakdown and adverse biochemical or inflammatory processes
– STICH I, published in 2005, remains the largest trial (with a sample size
of 1033 subjects) to test this hypothesis) no benefit in 6-month
favorable outcome in the surgical group (26%) compared with the
medical group (24%, P=0.41
– subjects with lobar ICH ≤1 cm from the brain surface who underwent
surgery had an 8% absolute increase in good outcomes
– STICH II – 607 patients - primary outcome of the trial, measured as
favorable outcome on the Extended Glasgow Outcome Scale, did not
reach statistical significance
www.theneurosim.com

23. • a subgroup analysis on the effect of baseline prognosis (poor versus
good) identified an interaction, such that subjects in the poor
prognosis group randomized to surgery were more likely to have a
favorable outcome than those randomized to medical care
• Subjects who were judged in need of surgery were not enrolled.
• 26% of subjects randomized to medical management ultimately
crossed over to surgery. In STICH II, 21% of subjects crossed over to
surgery. These subjects were typically sicker, with lower GCS scores
and larger hematomas.
• If none of these patients had undergone surgery, the rates of poor
outcome and death in the medical group may have been higher
• minimally invasive hematoma drainage assisted by tissue
plasminogen activator infusion; the Minimally Invasive Surgery plus
rtPA for Intracerebral Hemorrhage Evacuation (MISTIE) I and MISTIE
II trials have been completed, and a phase III trial is being organized
www.theneurosim.com

24. • MISTIE II trial = clot lysis through infusion rtPA
via burr hole showed improved outcomes past
180 days vs medical mx. 8% rtPa group to
Nhome vs 21% of medical mx and35% shorter
hospital stay in rtPA ,
• Phase 3 trial onging
www.theneurosim.com

25. • Long-term prognosis after intracerebral haemorrhage:
systematic review and meta-analysis. Poon MTC, et al. J
Neurol Neurosurg Psychiatry 2014;85:660–667
– This systematic review and meta-analysis (>30 days)
outcome after spontaneous ‘primary’ ICH = 1-year survival
was 46.0% and 5-year survival was 29.2%
– predictors of death in the long term were increasing age,
decreasing Glasgow Coma Scale score, increasing ICH
volume, presence of intraventricular haemorrhage and
deep/infratentorial ICH location, which are the principal
components of the ICH score
– Less than a half of patients with ICH survive 1 year and less
than a third survive 5 years. Risks of recurrent ICH and
ischaemic stroke after ICH appear similar after ICH,
provoking uncertainties about the use of antithrombotic
drugs.
www.theneurosim.com

26. In Sum
• If you are going to bang your head, have an EDH not an ASDH
• If you’re over 65 with an ASDH your chance of being able to look after yourself without
help is about 40% (but that’s only if you’re not in the 35% who die perioperatively)
• So have your clot evacuated and your Warfarin reversed
• If you have a CSDH and are over 90 years old, have it in Tokyo not New Mexico
• Being a girl is still a slightly risky business for SAH - especially if you smoke, drink and
have high blood pressure
• Have your aneurysm coiled if possible (unless you’ve had a subdural – then have it
clipped whilst you have your clot evacuated) and your vasospasm treated with
hypertension – not lots of fluids
• And if you’re pregnant try to have your SAH after 28 weeks so baby can be delivered – if
not clipping provides the better occlusion – but whichever you choose – have your
aneurysm secured
• Try not to have an haemorrhagic stroke – and certainly not one with a spot sign on
contrast CT
• If you do then have your clot evacuated if your prognosis is poor or if it’s in your post
fossa
• If your prognosis isn’t so awful – have some rTPA lysis rather than a craniotomy whilst you
have your BP controlled
• And overall be managed in a centre that has experience at dealing with these things
(preferably in Tokyo!!)
www.theneurosim.com

27. • Outcome of contemporary surgery for chronic subdural haematoma: evidence
based review. R Weigel, P Schmiedek, and J Krauss. J Neurol Neurosurg Psychiatry.
2003 Jul; 74(7): 937–943
• Surgical management of chronic subdural haematoma: one hole or two? Smith
MD1, Kishikova L, Norris JM. Int J Surg. 2012;10(9):450-2.
• Outcome after acute traumatic subdural and epidural haematoma in Switzerland:
a single-centre experience. Taussky P1, Widmer HR, Takala J, Fandino J.
SWISS MED WKLY 20 08;138(19–20):281–285
• The current role of decompressive craniectomy in the management of neurological
emergencies. S. Honeybul, & K. M. Ho. Brain Inj, 2013; 27(9): 979–991
• Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised
placebo-controlled trial . Sanne M Dorhout Mees,a,* Ale Algra,a,b W Peter
Vandertop,d Fop van Kooten,e Hans AJM Kuijsten,f Jelis Boiten,g Robert J van
Oostenbrugge,h Rustam Al-Shahi Salman,i Pablo M Lavados,j Gabriel JE Rinkel,a and
Walter M van den Berghc Lancet. 2012 Jul 7; 380(9836): 44–49.
www.theneurosim.com

28. • Age and Salvageability: Analysis of Outcome of Patients Older than 65 Years
Undergoing Craniotomy for Acute Traumatic Subdural Hematoma. Taussky,
et al WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.10.030
• Aneurysmal acute subdural hemorrhage: Prognostic factors associated with
treatment. Kulwin et al. Journal of Clinical Neuroscience 21 (2014) 1333–
1336
• The current role of decompressive craniectomy in the management of
neurological emergencies. Honeybul. Brain Inj, 2013; 27(9): 979–991
• Extradural haematoma—To evacuate or not? Revisiting treatment
guidelines. Zakaria et al. Clinical Neurology and Neurosurgery 115 (2013)
1201–1205
• Glasgow Coma Scale on admission is correlated with postoperative Glasgow
Outcome Scale in chronic subdural hematoma. Amirjamshidi et al. Journal of
Clinical Neuroscience 14 (2007) 1240–1241
• Advances in the management of intracerebral hemorrhage. Kuramatsu et al.
J Neural Transm (2013) 120:S35–S41
• Neuroimaging in Intracerebral Hemorrhage. Macellari et al. Stroke.
2014;45:903-908.)
www.theneurosim.com

29. • Outcome of acute and chronic subdural hematomas in patient 90 years
and older. Stippler et al, 3.cns.org/dp/2012CNS/419.pdf
• Outcome after acute traumatic subdural and epidural haematoma in
Switzerland: a single-centre experience. Taussky et al, SWISS MED WKLY
20 08;138(19–20):281–285
• Subarachnoid Haemorrhage from Intracranial Aneurysms during
Pregnancy and the Peurperium. Kataoka et al, Neurol Med Chir (Tokyo)
53,549-554. 2013
• Surgery for Intracerebral Hemorrhage Moving Forward or Making Circles?
Flaherty. Stroke. 2013;44:2953-2954.
• Traumatic brain injury: intensive care management. Helmy et al. Br J
Anaesth 2007; 99: 32–42
• Chronic Subdural Hematoma in Patients Over 90 Years Old in a Super-Aged
Society. Tabuchi. J Clin Med Res. 2014;6(5):379-383
• Effect of different components of triple-H therapy on cerebral perfusion in
patients with aneurysmal subarachnoid haemorrhage: a systematic
review. Dankbaar et al. Critical Care 2010, 14:R23
• Long-term prognosis after intracerebral haemorrhage: systematic review
and meta-analysis. Poon MTC, et al. J Neurol Neurosurg Psychiatry
2014;85:660–667
• New Developments in the Treatment of Intracerebral Hemorrhage.
Gomes. Neurol Clin 31 (2013) 721–735
www.theneurosim.com