Intracerebral haemorrhage by MikeJenny


									                                                                                                                                              Congress report

Intracerebral haemorrhage
Karl Schaller, Philippe Bijlenga
Depar tment of Neurosurger y, University of Geneva Medical Centre, Faculty of Medicine, University of Geneva, Geneva, Switzerland

Funding/potential conflict of interest: No funding. No conflict of interest.

                 What is the epidemiology of spontaneous intra­                                   negatively through increased rates of secondary complica-
                 cerebral haemorrhage (ICH)?                                                      tions in the course of the disease.

                 The incidence of ICH in the general population is 12–15/
                 10 000 per year, but reaches its peak of approx. 100/100 000                     What are the causes and risk factors of intracerebral
                 persons per year in the population >75 years of age. It is                       haemorrhage (ICH), and how does it occur?
                 responsible for 8–15% of all strokes in Europe and in North
                 America, whereas in Japan and in China it accounts for                           Causes of ICH are as follows (frequent or rare according to the
                 20–30% of all strokes. The 30-day mortality ranges from                          setting in a tertiary referral centre in Europe):
                 35–50% and is thus 2–6 times that for ischaemic stroke                           – Hypertensive haemorrhage (frequent)
                 [1, 3].                                                                          – Amyloid angiopathy (frequent)
                     The management and prognosis of young patients                               – Coagulopathy (frequent)
                 presenting with ICH is entirely different as treatable pathol-                   – Vascular malformations (AVM, cavernoma, aneurysm)
                 ogies are usually the underlying cause, e.g., vascular mal-                          (frequent)
                 formations (AVM, cavernomas etc.) or aneurysms, to name                          – Haemorrhagic transformation of ischaemic infarction
                 but a few.                                                                           (frequent)
                                                                                                  – Drug abuse (cocaine) (rare)
                                                                                                  – Tumours (rare)
                 Do prognostic criteria exist, and what are                                       – Vasculitis / encephalitis (rare)
                 the consequences of spontaneous ICH?                                             – Venous occlusion with consecutive haemorrhagic trans-
                                                                                                      formation (rare)
                 The prognostic criteria associated with outcome are as
                 follows:                                                                         Risk factors of ICH:
                 – Initial level of consciousness, e.g., according to the                         – Hypertension
                      Glasgow Coma Scale (GCS)                                                    – Atherosclerosis
                 – Localisation of the haematoma                                                  – Hypocholesterolaemia
                 – Haematoma volume                                                               – Previous brain infarction (increased 5–22 times com-
                 – Additional ventricular haemorrhage                                                 pared with the normal population)
                 – Presence of midline shift                                                      – Anticoagulants (increased 6–11 times compared with
                 – Additional hydrocephalus                                                           the normal population)
                 – Advanced age                                                                   – Alcohol (increased 5 times compared with the normal
                 – Neurological status on admission                                                   population)
                      Of these factors, low GCS grade and large haematoma                         – Amyloid-angiopathy
                 volume are the most predictive of poor outcome. Mortality                        – Advanced age (>65 years)
                 also relates to anatomical localisation of the haemorrhage,                          There seems to be a genetic disposition for lobar ICH
                 being highest in brainstem ICH.                                                  in the presence of the apoEA2 or apoEA4 alleles. ICH, par-
                      Only approx. 20% of all affected patients may function                      ticularly in elderly patients, is frequently deeply located
                 independently six months after the ictus, and the lifetime                       or ganglionic, and relates to long-standing arterial hyperten-
                 cost per case is, according to the recent American literature,                   sion with concomitant atherosclerosis of small and fragile
                 USD 124 000. Chronic diseases of advanced age contribute                         end-arteries. Even lobar ICH in the elderly may have its
                                                                                                  origin in a degenerative process of small arteries, so-called
                                                                                                  cerebral amyloidosis.
                 Prof. Dr. med. Karl Schaller                                                         Once a haematoma has formed, the clot volume may
                 Department of Neurosurgery                                                       increase in approx. 30% of patients during the first 24
                 University of Geneva Medical Centre                                              hours. Morbidity and mortality are caused by the second-
                 Faculty of Medicine                                                              ary effects exerted by the haematoma, such as neurotoxicity,
                 University of Geneva
                 Rue Micheli-du-Crest 24
                                                                                                  neuronal ischaemia, and brain oedema: activation of the coag-
                 CH-1211 Genève                                                                   ulation cascade with rupture of the blood brain barrier due
                                                                  to haemoglobin toxicity, for example, triggers immunologi-

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                                                                                                                                         Congress report

cal reactions such as activation of the complement cascade,                      mortality or a better outcome, due to increased frequency of
i.e., increased serum MMP3 correlates with mortality. In                         thromboembolic events [4].
parallel, increased intracranial pressure (ICP) leads to re-                         Management of supratentorial ICH remains, in conclusion,
duction of cerebral perfusion pressure (CPP), loss of cerebral                   conservative and supportive. It should focus on reduction
autoregulation and secondary liberation of vasoactive in-                        of increased ICP, restoration of cerebral blood flow, and
flammatory metabolites.                                                          avoidance of secondary complications [2, 3]:
                                                                                 – Take a precise clinical and patient history!
                                                                                  – Perform a precise neurological exam (including GCS)
What diagnostic measures should be taken in ICH?                                  – Assessment of respiratory and circulatory situation
                                                                                  – Keep upper part of body at 30°
After clinical assessment, the most important measure is                          – Ensure adequate oxygenation
cranial computed tomography (CCT). Recent CCT technol-                            – Sedation in unstable patients (to be maintained on
ogy allows simultaneous angiography (CTa), and underly-                              neurological ICU)
ing vascular malformations can thereby be excluded. If in                         – Reverse anticoagulation (if INR >1.4) (PCC, FFP, vitamin
doubt, however, additional 3D digital subtraction angio-                             K)
graphy (DSA) should be performed if feasible. MRI plays a                         – MAP <130 mm Hg (180/110 in hypertensives)
minor role in primary diagnostics due to limited access in                        – ECG surveillance
ventilated patients. It may however be important during                           – Avoid excessive hypo-/hypertension (ensure physiolo-
the further clinical course, e.g., for determination of brain                        gical CPP!)
damage, for perfusion imaging, and for exclusion or visuali-                      – Although the role of hyperosmolar substances is unclear,
sation of vascular malformations.                                                    they may be administered
    It is of the utmost importance to rule out treatable                          – Sensitive temperature management (fever worsens
pathologies such as cerebral AVMs, cavernomas, aneurysms,                            prognosis)
or dural AV fistulas as the underlying cause. Particularly in                     – Control laboratory values regularly (e.g., creatinine, INR,
young(er) patients, ICH should be regarded as due to rup-                            PTT, glucose, etc.)
ture of some form of vascular malformation, until proven                          – Perform frequent neurological/circulatory monitoring
otherwise.                                                                           (apply cuff, or arterial line, and central venous line)
                                                                                  – (External drainage in case of concomitant hydrocephalus
                                                                                     independently of estimated prognosis)
What are the therapeutic options, and how should                                     The position with regard to infratentorial, or cerebellar, ICH
ICH be managed?                                                                  is different: surgical management of these haematomas
                                                                                 improves prognosis and they should be operated upon if
As in the case of supratentorial ICH, unfortunately no ideal                     they do not extend into the brainstem [1].
and promising treatment regimen exists. Thus it is immate-                           Intense joint efforts are required from clinical and ba-
rial whether these patients are treated surgically (via open                     sic neuroscientists of all groups, together with internists
craniotomy, stereotactic aspiration and haematoma lysis,                         and intensivists, in order to develop preventive measures or
or endoscopically), or receive intensive care based on a con-                    reasonable treatment options for ICH – particularly in our
servative internistic/neurological regimen. Thus it is fully                     ageing societies.
justified for neurosurgeons to refrain from expensive surgi-                     Key words: ICH; conservative treatment; surgery; management
cal therapy of whatever type (open craniotomy, stereotac-
tic aspiration and haematoma lysis/drainage, or endoscopic                       References
aspiration). This almost fatalistic attitude has been substan-
                                                                                 1   Adeoye O, Woo D, Haverbusch M, Sekar P, Moomaw CJ, Broderick J,
tiated by an international multi-centre study (STICH trial) in                       Flaherty ML. Surgical management and case-fatality rates of intracerebral
more than 1000 patients in whom no difference in outcome                             hemorrhage in 1988 and 2005. Neurosurgery. 2008;63:1113–8.
                                                                                 2   Anderson CS. Medical management of acute intracerebral hemorrhage.
was noted between the groups, who received either intial                             Curr Opin Crit Care. 2009;15(2):93–8.
surgical treatment or conservative treatment respectively                        3   Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al.;
                                                                                     American Heart Association/American Stroke Association Stroke Council;
[5]. However, if patients with additional VEH are excluded                           American Heart Association/American Stroke Association High Blood
from the surgical group there may be some beneficial effect                          Pressure Research Council; Quality of Care and Outcomes in Research
from surgery. It is intended to elucidate this further through                       Interdisciplinary Working Group. Guidelines for the management of spon-
                                                                                     taneous intracerebral hemorrhage in adults: 2007 update: a guideline
the consecutive STICH II trial, which may help to identify a                         from the American Heart Association/American Stroke Association Stroke
group which would possibly benefit from surgery. For exam-                           Council, High Blood Pressure Research Council, and the Quality of Care
                                                                                     and Outcomes in Research Interdisciplinary Working Group. Circulation.
ple, the management of lobar haemorrhage in hypertensive                             2007;116(16):e391–413.
patients aged between 45 and 70 is still controversial, and                      4   Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al.;
                                                                                     Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investiga-
thus it is justifiable to decide according to department policy
                                                                                     tors. Recombinant activated factor VII for acute intracerebral hemorrhage.
and/or on a case-by-case basis. The subgroup analysis of the                         N Engl J Med. 2005;352(8):777–85.
STICH trial suggested that this group may benefit from sur-                      5   Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM,
                                                                                     Hope DT, et al. for the STICH investigators: Early surgery versus initial
gical evacuation of the haematoma [6].                                               conservative treatment in patients with spontaneous supratentorial in-
     A large randomised trial of the use of recombinant fac-                         tracerebral haematomas in the International Surgical Trial in Intracerebral
                                                                                     Haemorrhage (STICH): a randomised trial. Lancet. 2005;365:387–97.
tor VIIa (rFVIIa) showed that secondary haematoma growth                         6   Mendelow AD, Unterberg A. Surgical treatment of intracerebral haemor-
could be reduced, but this did not translate into reduced                            rhage. Curr Opin Crit Care. 2007;13:169–74.

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