Spontaneous Intracerebral Hemorrhage Dr Osamah Al Baker

							Spontaneous Intracerebral Hemorrhage

Osamah Al-Baker, MD Assistant professor Neurology consultant Kuwait Univeristy

Objective
• • • • • • Epidemiology Etiology/ Risk Factors Clinical Manifestation H&P Diagnostic procedures Treatment Prognosis/Outcome

Epidemiology
• Each year in US, 37,000-52,400 people suffer an ICH • SICH accounts for 10-15% of all strokes • SICH is associated with higher mortality than either ischemic stroke or SAH • Only 38% of affected persons surviving 1 year

Epidemiology
• Variation in incidence is seen among diff. Sex, age groups, & races • Circardian & circannual pattern of SICH onset in morning and winter has been reported
Broderick, NEJM, 1992

Etiology
• Primary ICH 80% • Secondary 20% + Congenital + Acquired
- Vascular - Coagulopathy - Neoplasm - Pregnancy - Drugs - Unknown - Trauma** - Hemorrhagic ischemic stroke

Primary SICH (80%)
• Sponataneous rupture of small vessels damaged by HTN or amyloid angiopathy • Hypertensive bleed – certain location • Charcoat- Bouchard aneurysm, lipohyalinosis

• Recurrent lobar Hg in elderly • B-amyloid protein is deposited in media & adventitia of cortical and leptomeningeal vessels • Apo-lipoprotein E genotype • Hereditary ICH with amyloidosis-Dutch type is rare AD of CAA

Cerebral Amyloid Angiopathy (CAA)

CAA

Secondary SICH (20%)
• Vascular anomalies are 2nd most common cause of SICH • Structural vascular lesions are most common cause of SICH in children.
• Aneurysm • AV malformation • Cavernoma/cavernous haemangioma • Dural Arteriovenous fistula

Vascular anomaly

SAH-Aneurysm

AVM

Tumor
• Tumor hemorrhage occur in 10% of all primary or metastatic tumor + Primary GBM, hemangioblastoma, oligodendroglioma + Metastatic tumor Melanoma, renal cell Ca, lung, thyroid ,Breast and prostate cancer

Other Causes of ICH
• Liver failure and coagulopathy • Drug abuse ( Cocaine, ecstasy, amphetamine)
- Most common cause of stroke in young adult. - Vascular anomaly is seen in 10/11 patients with SICH+ - Diagnostic work-up is needed in these patients

• • • • •

Drugs ( Sympathomimetic, Gingko,….) Moya-Moya disease. Pregnancy Rare causes ( infection, DIC,..) Unknown + McEvoy, Lancet, 1998

Risk Factors
• Non- modifiable ( age, sex, race, ..) • Modifiable Risk factors - Hypertension * - Moderate/Heavy alcohol intake** - Anticoagulant Treatment** - Cigarette smoking (SAH, associated with ICH) - DM ( associated with ICH>SAH) - ? Hypocholesterolemia, Hepatitis C***
** Juvela, Stroke, 1995 * SHEP, JAMA, 1991 ***Karibe, J Clin Neurosci, 2001

Prevention of SICH
• Hypertension treatment • Control of alcohol intake and sympathomimetic drug abuse • Careful monitoring of anticoagulation level in patients taking warfarin • Diligent selection of patient for thrombolytic treatment for MI & acute ischemic stroke

Clinical Manifestation
Initial presentation
• Sudden onset of focal neurologic deficit with H/A, Nausea, vomiting, & altered LOC. • Elevated Blood pressure (90%) • Seizures occurs in 10% of patients • Type of focal deficits depend on hematoma location

SICH Location

Hematoma Location

Clinical Manifestation
• Basal ganglia (50%)
Contralateral hemiparesis, sensory loss, conjugate gaze toward Hg site

• Lobar regions (20-50%)
Contralateral hemiparesis or sensory loss, aphasia, neglect, or confusion

• Thalamus (10-15%)
Contralateral hemiparesis, sensory loss, Downward & inward deviation of eyes, reduced vertical gaze

• Pons (5-12%)
– Quadriparesis, facial weakness, decreased level consciousness, small reactive pupil

• Cerebellum (1-5%)
– Ataxia, miosis, gaze paresis

Vital signs Level of conscious Pupil exam cranial nerve exam cerebellar exam Motor Sensory

Clinical Manifestation
Initial presentation
• Hydrocephalus • Raised ICP • Herniation syndrome

Clinical Manifestation
Hematoma enlargement
• ¼ patients further deterioration in LOC within the 1st 24 hours after onset • Hematoma enlargement occurs in 18-38% of ICH patients scanned within 3 hr of onset* • After 3 hr, only 11% of patients show hematoma enlargement. • Mechanism: ? Rupture of surrounding veins.** • Potential predictors of hematoma enlargement: Thalamic ICH, large initial Hg, SBP>160, DM
*Brut, Broderick, Stroke, 1997, **Kazui, Stroke,1996

Clinical Manifestation
Perihamatoma edema
• Typically develops over 1st 3-96 hours • Vasogenic & cytotoxic edema occur initially • Interstitial and osmotic edema develop later • RBC breakdown product and thrombin

Predictors of Mortality in ICH
• • • • • • • • GCS at presentation(<8)* Hematoma size (> 60ml)* Pulse pressure MABP Glucose Intraventricular rupture* Hematoma enlargement Relative volume edema

Gebel, Stroke, 2002

Emergency Evaluation of ICH
first 15 minutes
• ABCs • Consult Neurology • Document HX&PE - Especially time last known to be normal - Not when symptoms first noted … • Blood work ( CBC, PT,INR,toxicology) • EKG, CXR • Send for imaging

Diagnostic Procedure
• CT scan • MRI • Cerebral angiography

CT Scan
• CT Head is the imaging procedure of choice in the initial evaluation of suspected ICH (level of evidence I, grade A recommendation).

• Hematoma Location & size=
AXBXC/2

• HCP, edema, Herniation, IVH

MRI scan
• Identify Brain tumor •

Cerebral Angiogram

Cerebral Angiogram

Goals of ICH therapy
• Prevent hematoma enlargement
+ Up to 1/3 of patients, time dependent + There are no proven ways to stop bleeding
- Blood pressure treatment - Hemostatic agents - Surgery.

• Limit injury ( neuroprotection) + Raised ICP
- Hyperventilation, osmotic agent, - ICP monitors, ventricular drainage - Surgery: open decompression ,endoscopic

+ Glycemia : Same argument as ischemi stroke + Core body temperature : Same Rx

Medical Treatment
• • • • Critical care Seizure prophylaxis Blood pressure management Management of Intracranial Hypertension

ICU admission
• Risk of clinical deterioration after SICH is greatest during 1st 24 hours • Maintain Euvolemia & normoglycemia • Enteral nutrition • DVT prophylaxis • Gastric cytoprotection • PT, OT, & speech therapy

Seizure prophylaxis
• Seizure more frequent in ICH than ischemic stroke* • Most seizures occur within 1st 24 hours • Risk of seizure depend on hematoma location*/** • Epilepsy is more likely in late-onset siezure (>2 wks after SICH)*
* Bladin, Arch Neurol, 2000 * *Cervoni,Neurosurg Rev,1994

Acute ICH- Blood Pressure
• No Studies showing clear benefit • Highest BPs associated with ICH Growth • Generally more aggressive than for ischemic stroke - Balancing risk of continued hemorrhage from too high BP with risk of ischemia in setting of ICP from too low BP
Stroke. 1999; 30:905-915 Guideline for the management of spontaneous intracerebral hemorrhage

Acute ICH-Blood Prssure

ICP
• ICP in herniation syndrome& death
• Goal to Keep ICP<20mmhg, and CPP> 70 mmhg

• ICP moniter in patient with GCS <9 • Treatment of raised ICP: - Head elevation - CSF drainage - Osmotic therapy - Hyperventilation - Sedation - Surgery

Acute ICH- Hemostatic Agent
• Donar Blood products
-HMC reversal protocols for patients on antithrombotic agents • Anti-fibrinolytic agents

• rFVIIa (Novoseven)
- seem safe in phase II study - Phase IIb study with suggestion of efficacy?

Iatrogenic ICH management
• Warfarin associated ICH
- FFP 20 ml/Kg - FVIIa - Vit. K 1 mg (INR 4.5-10) 8-24 hr to correct PT

• Heparin associated ICH - Discontinue drug and give 1% protamine sulfate over 10-20 minutes
( 1mg neutralize 100 USP heparin unit)

• Thrombolytic associated ICH
-10 units cryoprecipitate, 2 U FFP every 6 hrs for 24hrs with 4-6 units platelets concentrate until fibrinogen levels are >11.1 mmol/L

rFVIIa for acute ICH
• FDA approved for hemophilia - being used for emergent warfarin reversal rescue in uncontrollable bleeding • International Randomized Trial - 400 patients - Placebo,40,80,160 mcg/KG - Scan within 3 hours, drug within 4 hours

rFVIIa for acute ICH
World Stroke Congress, Vancouver BC, June 2004
* NS increase in Thrombotic events, 5.6%( 7 strokes, 7MIs)

Outcome

Placebo

40 mcg/Kg

80 mcg/Kg

160 mcg/Kg

Sig?

% ICH 29% growth
% mortality

16% 18%
45%

14% 18%
47%

11% 19%
45%

Yes No
Yes

29%

% Good 31% outcome

rFVII for acute ICH
Recommended Uses
• ICH on warfarin • ICH < 4 hours from onset • ICH with expanding hematoma - CTA can give answer with one scan

Thrombolytic therapy for ICH
• Thrombolytic agent to reduce ICH/IVH • IVH complicates 40% of ICH obstructive HCP and mass effect • Urokinase in EVD reduce mortality from 58% to 25% at 1 month*. • Phase II trial in underway
*Naff, Stroke, 2000

Acute ICH-Surgery
• No randomized trials showing benefit
- may reduce mortality in larger hemorrhage
- Std craniotomy, endoscopic and needle aspiration

Stroke.2000,31:2511. Neurology 2001;56:1294-1299 Neurology 2001; 56:766-772. Stroke.1999;2025-2032

Meta-analyses of Surgical Trials
Metaanalysis Studies Analyzed
McKissock, Juvela, Auer, Batjer Odds of death or dependency with surgery 1.23(0.77-1.98)

Conclusion s

Hankey & Hon Prasad et al Saver et al
Fernandes et al

Insufficient evidence Insufficient evidence

McKissock, Juvela, Auer, Batjer Juvela, Auer, Batjer
McKissock, Juvela, Auer, Batjer, Chen, Morgenstern, Zuccarello

1.99(0.92-4.31)

0.72 (0.38-1.44) Trends toward improved outcome

1.20 (0.83-1.74)

Trends toward improved outcome

International Surgical Trial Intra-cerebral Hemorrhage (ISTICH)
Mendelow. Lancet 2005

• 1033 patients , within 72 hours • Preliminary results - Good outcomes seen in * 26.01% of “early surgery”group * 23.8% of “ initial conservative “group * Difference NS - Patients with hematoma <1cm from cortical surface have better outcome

ICH Surgery Recommedation

Stroke.1999;30:905-915

Cerebellar ICH
• No randomized controlled studies. • Several series reported good outcomes with evacuation of hematama:
- > 3 cm in size - Brainstem compression/hydrocephalus

Surgical Treatment

Complications
•
Neurological – Seizures 10% – Increased ICP • Pulmonary – Aspiration – Pneumonia • Cardiovascular – Cardiac arrhythmias – DVT/PE • GI/GU – GI bleeding – Urinary tract infection – Bowel impaction – Malnutrition • Integumentary – Pressure ulcers • Musculoskeletal – Impaired mobility – Contractures – Heterotrophic ossification – Spasticity • Psychcosocial – Depression – 60% – Loss of self esteem