Intracerebral Haemorrhage.Dr NG NeuroEdu

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Intracerebral Haemorrhage.Dr NG NeuroEdu

  1. 1. Intracerebral Haemorrhage Dr Nishantha Gunasekera MBBS, MS, MRCS Consultant Neurosurgeon Department of Neurosurgery Teaching Hospital Karapitiya Ruhunu Clinical Society Meeting November 2012
  2. 2. Intracerebral Haemorrhage • Second most common form of stroke (15-30%) • Onset smooth and progressive – unlike ischeamic stroke • Unenhanced CT brain -1st investigation • Volume correlates to mortality, morbidity (Modified Elipsoid Volume = axbxc/2) • Clot enlarges in ~33% of cases within 3 hours • Angiography recommended (except >45y, thalamic, putamen, post.fossa ICH) • F VIIa given within 4 hrs to limit volume • Role of surgery
  3. 3. Intracerebral Haemorrhage • Epidemiology /risk factors • 12-15/100,000 per year • Twice the incidence of SAH • Incidence increases after 55yrs. • Doubles with each decade till 80yrs and after 80yrs, 25 times the previous decade • More common in men • Previous CVA (any) increases risk 23:1 • Alcohol (>3 drinks a day increases risk ~x7) • Smoking ? • Liver dysfunction
  4. 4. Intracerebral Haemorrhage2520 20 19 18 16 16 16 16 1615 15 15 15 15 15 15 15 15 14 14 14 14 13 13 13 13 13 12 12 12 12 11 11 11 11 11 1110 10 10 10 10 10 10 10 10 10 10 10 10 9 9 9 9 9 9 9 9 9 8 8 8 8 8 8 8 8 7 7 7 7 6 6 6 6 6 6 6 6 6 6 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 4 4 3 2 1 0 Decomp.Cr. C-SDH EDH ICH EVD VP Shunt Data: Dept. Neurosurgery THK Audit 2011/2012
  5. 5. Intracerebral Haemorrhage • Check list for adult ICH • Hypertension • Drugs • Alcohol abuse • Coagulopathies • Leukeamia • Previous stroke • Vascular anomalies (AVM, Venous angioma…) • Tumour (renal, breast, melanoma) • Recent surgery (carotid endarterectomy, heparin) • Recent childbirth (eclampsia, preeclampsia) • Recent Trauma
  6. 6. Intracerebral Haemorrhage • Aetiologies 1. Hypertension – Cause or effect? 2. Acute increase in cerebral blood flow 3. Vascular anomalies 4. Arteriopathies 5. Brain tumours 6. Coagulation/ clotting disorders 7. CNS infections
  7. 7. Intracerebral Haemorrhage • Aetiologies cntd.. 8. Venous/dural sinus thrombosis 9. Drug related 10. Post trumatic 11. Pregnancy related (post partum angiopathy) 12. Post Operative 13. Idiopathic
  8. 8. Intracerebral HaemorrhageHistory CommentTime of onset (time the patient was lastnormal)Vascular risk factors Hypertension, diabetes, hypercholesterolae mia, smokingMedications Anticoagulants, antiplatelets, decongestants , antihypertensives, stimulants, sympathomi meticsRecent trauma or surgery Carotid endarterectomy or carotid stenting in particular as ICH may be related to hyperperfusion after such procedures. Traumatic aneurysms!Dementia Associated with amyloid angiopathyAlcohol or illicit drug use Cocaine and other sympathomimetic drugs are associated with ICH, stimulantsSeizuresLiver disease coagulopathyCancer and haematologic disorders coagulopathy
  9. 9. Intracerebral HaemorrhagePhysical Examination CommentsVital signs Fever associated with early neurologic deterioration (?aspiration) Higher initial BP associated with early deterioration and higher mortalityA general physical exam focusing on head, ?traumaheart, lungs, abdomen and extremitiesA thorough but time urgent neurologic A structured exam such as the Nationalexam Institutes of Health Stroke Scale (NIHSS) can be completed in minutes and provides a quantification that allows easy communication of severity of the event to care givers. We use the Glasgow Coma Scale whose initial score is a strong predictor of outcome
  10. 10. Intracerebral Haemorrhage • Microaneurysms of Charcot-Bouchard – AKA milliary aneurysms – From small branches of the lateral lenticulo-striate arteries in basal ganglia – Possible origin of the “hypertensive ICH” of basal ganglia
  11. 11. Intracerbral Haemorrhage • Cereberal Amyloid Angiopathy (CAA) – AKA Congophilic angiopathy – Present in >50% of patients >70yrs – May present with a TIA like prodrome – Suspect in patients with recurrent ICHs – Lobar in location – Gradient echo MRI will identify small haemorrhages or haemosiderin in cortical areas – Pathogenic deposits of Beta Amyloid Protein (“apple green” birefringence under polarised light)
  12. 12. Intracerebral Haemorrhage ICH Score (Hemphill et al.)Feature Finding Points ICH Score 30 Day MortalityGCS 3-4 2 5-12 1 0 0% 13-15 0 1 13%Age >=80 1 <80 0 2 26%Location Infratentorial 1 Supratentorial 0 3 72%ICH volume >=30cc 1 4 97% <30cc 0Intraventricular Yes 1 5 100%Blood No 0 6 100%ICH SCORE 0-6 points
  13. 13. Intracerebral Haemorrhage Thinking About Interventions • Class I evidence Conditions for which there is evidence for and general agreement that the procedure or treatment is useful and effective • Class II evidence Conditions for which there is conflicting evidence and divergence of opinion about usefulness and effectiveness of the procedure/treatment • Class III evidence Conditons for which there is evidence and general agreement that the procedure or treatment is NOT useful or effective and in some cases may be harmful
  14. 14. Intracerebral Haemorrhage Therapeutic recommendations Level of evidence A Data from MRCT Level of evidence B Data from SRCT Level of evidence C Consensus of opinion of experts, case studies or standard of care MRCT- Multiple Randomized Clinical Trials (meta-analyses) SRCT – Single Randomized Clinical Trial
  15. 15. Intracerebral Haemorrhage Diagnostic Recommendations Level of Evidence A Data from prospective cohort studies using a reference standard applied by a masked evaluator Level of Evidence B Data from one or more case control studies or studies using a reference standard applied by an unmasked evaluator Level of Evidence C Consensus of opinion of Experts
  16. 16. Intracerebral Haemorrhage Neuroimaging Non contrast CT
  17. 17. Intracerebral Haemorrhage CT Angiogram
  18. 18. Intracerebral Haemorrhage CT angio reconstruction
  19. 19. Intracerebral Haemorrhage • Rapid neuroimaging with CT or MRI is recommended to distinguish ischaemic stroke from ICH- Class I • CT angiography and contrast CT maybe considered to help identify patients at risk for haematoma expansion – Class II • CT angiography, CT venography, C+CT, C+MRI, MTA, MRV maybe useful to identify structural lesions (AVM, Tumour) – Class II
  20. 20. Intracerebral Haemorrhage • Spot sign Contrast extravasates into ICH May predict expansion of ICH Delgado Almadoz et al. Stroke,40(9):2994.2009
  21. 21. Intracerebral Haemorrhag • Anticoagulation and ICH Leads to more Haematoma growth and higher mortality - Reverse warfarin promptly and aggressively - FFP or Prothrombin Complex Concentrates (PCC eg.novo VII ) - IV vitamin K Patients with sever coagulation factor deficiency or severe thrombocytopaenia should receive appropriate factor replacement therapy or platelets, respectively Class I, Evidence C
  22. 22. Intracerebral Haemorrhage • Patients with elevated INR due to OAC should have there warfarin withheld , receive therapy to replace vitamin K- dependent factors and correct INR and receive Intravenous vitamin K Class I, Evidence C • PCC have not shown improved outcomes compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP Class II, Evidence B
  23. 23. Intracerebral Haemorrhage • The usefulness of platelet transfusion in ICH patients with a history of antiplatelet use is unclear and is considered investigational Class II, Evidence B • Practically we still do it despite the lack of platelet function tests
  24. 24. Intracerebral Haemorrhage • Haematoma Expansion – Common – 103 pts. Prospective observation study with serial CTs (baseline, 1hr and 20 hrs following ICH) – 26% showed > 33% enlargement on 1hr CT – 38% showed> 33% enlargement on 20 hr CT – Neurological deterioration correlated with haematoma expansion Brott T et al, Stroke.1997 Jan;28(1):1-5
  25. 25. Intracerebral Haemorrhage • Hypertension and ICH – INTERACT trial (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage) • 404 patients randomized into » Target SBP of 140mmHg within 1 hr or » Target SBP of 180mmHg – Trend toward lower haematoma growth in the lower BP group – No increase in adverse events related to lower BP Anderson CS, et al. Lancet Neurol.2008;7(5):391-399.
  26. 26. Intracerebral Haemorrhage – ATACH (Antihypertensive Treatment for Acute Cerebral Haemorrhage) • 80 ICH pts. • 4-tier, dose escalation of IV Nicardipine based lowering of BP • Confirmed safety and feasibility of early rapid BP lowering Qureshi Al.et al, for the ATACH Investigators Arch Neurol.2010May;67(5):570-6
  27. 27. Intracerebral Haemorrhage Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence Class II, Evidence C In patients presenting with a systolic BP of 150-220 mmHg, acute lowering of SBP to 140mmgHg is probably safe Class II, Evidence B
  28. 28. Intracerebral Haemorrhage • Recommended BP Treatment Targets – If SBP >200mmHG or MAP >150mmHg • then consider aggressive reduction of BP with continuous IV infusion, with frequent BP monitoring every 5 mins – If SBP > 180mmHg or MAP >130mmHg and there is a possibility of raised ICP • then consider monitoring ICP and reducing BP using intermittent or continuous IV meds. while maintaining CPP > 60mmHg
  29. 29. Intracerebral Haemorrhage – If SBP is >180mmHg or MAP is >130 and there is NO evidence of raised ICP • Then consider modest reduction of BP (eg. MAP 110, BP 160/90) using intermittent or continuous IV meds. while clinically examining the patient every 15 mins.
  30. 30. Intracerebral Haemorrhage • Other Medical Considerations – Initial management and monitoring in an ICU with physician and intensivist – Glucose should be monitored and normoglycaemia recommended – Intermittent pneumatic compression of calves – Clinical seizures treated with antiepileptics – Prophylactic antiepileptics NOT recommended
  31. 31. Intracerebral Haemorrhage • Hydrocephalus – May accompany ICH especially if intraventricular rupture – Elevates ICP – Results in early or delayed neurological deterioration – Surgery for evacuation of IVH/treatment of ventriculomegally
  32. 32. • Raised ICP Management Algorithm (Ideal)
  33. 33. Intracerebral Haemorrhage • Surgical Treatment of ICH – STICH trial (Surgical Treatment of Intracerebral Haemorrhage) Newcastle group – 902 ICH pts. randomized for early evacuation (<96hrs) vs medical management – Excluded cerebellar ICH – Only considered cases falling within the “uncertainty group” – Uncertainty group = group of patients for whom EITHER medical or surgical management would be considered
  34. 34. Intracerebral Haemorrhage No indication for surgery
  35. 35. Intracerebral Haemorrhage • If ICH >1cm from the cortical surface or GCS< 8 – Surgical patients tended to do worse than medical patients • If ICH <1cm from the surface – Patients tended to towards better outcomes with surgery but not significant (OR 0.69, 95%)
  36. 36. Intracerebral Haemorrhage • The Lancet, Volume 365, Issue 9457, Pages 387 - 397, 29 January 2005 • Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial • Original Text • Prof A David Mendelow , Barbara A Gregson , Helen M Fernandes , Gordon D Murray , Graham M Teasdale , D Terence Hope , Abbas Karimi , M Donald M Shaw , David H Barer , for the STICH investigatorsInvestigators listed at the end of report Selection Patients were eligible for inclusion if they had CT evidence of a spontaneous supratentorial intracerebral haemorrrhage that had arisen within 72 hours and if the responsible neurosurgeon was UNCERTAIN about the benefits of either treatment (clinical uncertainty principle) Interpretation Patients with spontaneous supratentorial intracerebral haemorrhage in neurosurgical units show no overall benefit from early surgery when compared with initial conservative treatment.
  37. 37. Intracerebral Haemorrhage • Surgical Management of ICH – For patients presenting with supratentorial lobar clots > 30 cc within 1cm of the surface, with clinical deterioration, evacuation via craniotomy is standard – For stable patients with smaller clots, surgery may be considered only if clinical deterioration occurs while under observation
  38. 38. Intracerebral Haemorrhage
  39. 39. Intracerebral Haemorrhage
  40. 40. Intracerebral Haemorrhage
  41. 41. Intracerebral Haemorrhage • Patients with cerebellar haemorrhage who are deteriorating or who have brain stem compression and or hydrocephalus should under go evacuation/ EVD as soon as possible • Ultra early removal of supratentorial ICH may not be safe due to ongoing bleeding • Minimally invasive clot evacuation is not standard and considered investigational
  42. 42. Intracerebral Haemorrhage • Risk factors for Recurrence – Lobar ICH – Older age – Anticoagulation – Apo E e2 or e4 alleles – Increased number of Microbleeds on MRI
  43. 43. Intracerebral Haemorrhage • Prevention of Recurrence – BP should be very well controlled particularly for patients with ICH location typical of hypernensive vasculopathy – Target of less than 140/90 (130/80 if diabetic or has CRD) is reasonable – Avoid long term anti-platelet drugs / anticoagulation without proper indications and follow up. • Every one gets aspirin/ clopidogrel etc etc!!
  44. 44. Intracerebral haemorrhage • Rehabilitation and Recovery – Multidisciplinary – As early as possible – Well coordinate “seamless” accelerated hospital discharge – Home based re-settlement
  45. 45. Thank you

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