Acute Care of Patients with Intracerebral Hemorrhage

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1 Acute Care of Patients with Intracerebral Hemorrhage Cyrus K. Dastur, MD Assistant Professor Director, Neurocritical Care Departments of Neurology and Neurological Surgery UC Irvine

2 None Declarations

3 Definitions Intracranial Hemorrhage (ICH) Subarachnoid Hemorrhage (SAH) Subdural Hematoma (SDH) Epidural Hematoma (EDH) Intraventricular Hemorrhage (IVH) Intracerebral/Intraparenchymal Hemorrhage (ICH/IPH)

4 Subarachnoid Hemorrahge

5 Subdural Hemorrhage

6 Epidural Hemorrhage

7 Epidural vs Subdural

8 Intraventricular Hemorrhage

9 Intracerebral/Intraparenchymal Hemorrhage

10 Intracerebral/Intraparenchymal Hemorrhage

11 History, History, History! Time & activity at onset Rapidity of deficits LOC, seizure, fall Physical Exam Tests EKG CXR Neuroimaging Non-contrast CT exam of brain CT Angiography MRI of brain Diagnosis

12

13 Labs CBC with platelets BMP PT/INR PTT Serum Glucose Pregnancy Test Toxicology Screen Troponin

14 General Medical Management

15 Blood Pressure Management Initial Goals Systolic Blood Pressure < 140 mmhg Minimum MAP > 65 mmhg Cerebral Perfusion Pressure >55 mmhg Initial Management Hold oral BP meds Short acting agents Labetalol Hydralazine Enalaprilat Nicardipine Esmolol CPP = MAP CPP

16 Figure 1. Early hematoma growth in a 48 year-old chronically hypertensive woman. Mayer S A Stroke. 2007;38: Copyright American Heart Association, Inc. All rights reserved.

17 ATACH I ( ) Pilot study Showed safety of early aggressive BP lowering to goal SBP<140 mmhg ATACH II (2012 ongoing) Multicenter, randomized Phase III trial Early aggressive treatment to SBP<140 vs SBP<180 mmhg Primary Endpoint reduce death & disability at 3 months after ICH by at least 10%

18 Coagulopathy Management Coagulation factor deficiency FFP, CPP, PCC, Factor VII Warfarin associated coagulopathy FFP, PCC, Factor VII IV Vit K Severe thrombocytopenia Platelet Transfusion

19 Complications of ICH CNS Complications ICH growth/expansion IVH extension and Hydrocephalus Raised intracranial pressure Cerebral edema Autonomic dysfunction Seizures Neurological Deficits Non-CNS Complications Cardiac Troponin leak, EKG changes, AMI, Takotsubo Cardiomyopathy Pulmonary Aspiration PNA, respiratory failure, CNS breathing patterns, ARDS, neurogenic pulmonary edema GI Ulcer, GI hemorrhage, illeus Neuroendocrine hyponatremia, relative adrenal insufficiency Heme DVT, PE Skin Decubitus Ulcers

20 Cerebral Edema/ICP management When to place EVD? GCS <8 Clinical evidence of transtentorial herniation Significant IVH or hydrocephalus CPP goal mmhg may be reasonable

21 Figure. Intracranial pressure treatment algorithm. Morgenstern L et al. Stroke 2010;41: Copyright American Heart Association, Inc. All rights reserved.

22 Surgery for ICH Majority of patients - usefulness of surgery unclear Exceptions Cerebellar ICH Deteriorating clinically Have brainstem compression Obstructive hydrocephalus Lobar clots >30 ml & within 1cm of surface Stereotactic/endoscopic aspiration with or without thrombolytics Investigational only at current time.

23 Glucose Management High glucose on admission associated with worse outcomes in ICH patients Unclear whether tight glucose control ( mg/dl) is beneficial, and may be harmful Normoglycemia should be maintained Hypoglycemia should be avoided

24 Seizures and Antiepileptics Clinical seizures should be treated Continuous EEG probably indicated if depressed mental status out of proportion to degree of brain injury Prophylactic anticonvulsant medications should NOT be used.

25 Fever Management Fever is not uncommon Clear association with worse outcome Aggressive treatment antipyretics, surface cooling, cold saline, intravascular cooling catheter

26 Hematoma Volume ABC/2 rule A x B x C / 2 A & B = diameters of hemorrhage (in cm) C = # of slices x slice thickness (in cm) (3 cm x 3 cm x (3 slices x 0.5cm)) / 2 = 13.5/2 = 6.75 cm 3

27 ICH Score

28 The ICH Score and 30-day mortality. Hemphill J C et al. Stroke. 2001;32: Copyright American Heart Association, Inc. All rights reserved.

29 DNR Orders Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.

30 Summary Different types of ICH High morbidity/mortality disease ABCs BP management Reversal of anticoagulation Avoid early prognositication

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