The document provides a comprehensive overview of intracranial hemorrhage, detailing various types such as epidural hematoma (EDH), subdural hematoma (SDH), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). It reviews treatment guidelines, outcomes based on different demographics, and the importance of timely surgical intervention while discussing the effects of management strategies on long-term survival. The document emphasizes the need for experience in healthcare settings when treating hemorrhagic strokes to improve patient prognosis.

1. Intracranial Haemorrhage
Barbara Stanley FRCA
Consultant Neuroanaesthetist
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2. Where to start??
• Intracranial hemorrhage (MeSH term) + 2010
– 2014 = 4839
• Review articles only = 246
• Each type of bleed – last 5 years on PubMed
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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
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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
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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
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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
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11. SDH
• Mortality uncomplicated ASDH = 20% but up
to 50% and even 70% in some studies (Taussky et al 2008)
• Why so bad?
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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
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13. Chronic SDH
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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)
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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
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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).
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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
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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
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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
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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)
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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
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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
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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
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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.
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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!!)
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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.
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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.)
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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
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