Medicine 5th year, 3rd lecture (Dr. Mohammed Tahir)

Intracranial HemorrhageIntracranial Hemorrhage

Marc Dorfman, MD, FACEP, MACP

Key Clinical QuestionsKey Clinical Questions• What are the most common What are the most common

etiologies and locations of ICH?etiologies and locations of ICH?• What are the goals of BP What are the goals of BP

management?management?• What are the optimal strategies for What are the optimal strategies for

managing ICP?managing ICP?• What other treatment modalities are What other treatment modalities are

available to the ED physcian?available to the ED physcian?


Key Clinical QuestionsKey Clinical Questions

• Which ICH patient require surgery?Which ICH patient require surgery?• How does hemorrhage volume How does hemorrhage volume

change over time? change over time? • Does hemorrhage volume growth Does hemorrhage volume growth

affect mortality?affect mortality?• What are the new therapies being What are the new therapies being

tested for this disease process?tested for this disease process?


Intracranial HemorrhageIntracranial Hemorrhage• EpidemiologyEpidemiology• EtiologyEtiology• DiagnosisDiagnosis• TreatmentTreatment

• BP managementBP management• Neurosurgical indicationsNeurosurgical indications• New treatment modalitiesNew treatment modalities


ICH EpidemiologyICH Epidemiology• 30 day mortality: 35-52%30 day mortality: 35-52%

• 50% of these in first 48 hours50% of these in first 48 hours

• One-fifth of survivors are One-fifth of survivors are independent at 6 monthsindependent at 6 months


ICH TypesICH Types• EpiduralEpidural• SubduralSubdural• SubarachnoidSubarachnoid• IntraparencymalIntraparencymal• IntraventricularIntraventricular• CerebellarCerebellar


Hypertensive ICHHypertensive ICH• HypertensionHypertension

• EssentialEssential• EclampsiaEclampsia• SympathomimeticsSympathomimetics

• CocaineCocaine• AmphetaminesAmphetamines• PhenylpropanolaminePhenylpropanolamine


Hypertensive ICHHypertensive ICH• Basal ganglia (50%)Basal ganglia (50%)

• Contralateral hemiparesis, sensory loss, conjugate Contralateral hemiparesis, sensory loss, conjugate gazegaze

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

neglect, or confusionneglect, or confusion• Thalamus (10-15%)Thalamus (10-15%)

• Contralateral hemiparesis, sensory loss, gaze Contralateral hemiparesis, sensory loss, gaze paresisparesis

• Pons (5-12%)Pons (5-12%)• Quadriparesis, facial weakness, decreased level Quadriparesis, facial weakness, decreased level

consciousnessconsciousness• Cerebellum (1-5%)Cerebellum (1-5%)

• Ataxia, miosis, gaze paresisAtaxia, miosis, gaze paresis


Other ICH EtiologiesOther ICH Etiologies• AmyloidAmyloid• TraumaTrauma• Vascular malformation-Avm, Vascular malformation-Avm,

cavernoushemangiomascavernoushemangiomas• AneurysmAneurysm• TumorTumor• CoagulopathyCoagulopathy• VasculitisVasculitis


ICH PresentationICH Presentation

• Hypertension (90%)Hypertension (90%)• Altered mental status (50%)Altered mental status (50%)• Headache (40%) Headache (40%) • Seizures (6-7%)Seizures (6-7%)


Intracerebral Hemorrhage Intracerebral Hemorrhage DiagnosisDiagnosisCT ScanCT Scan


ICH Rx Key ConceptsICH Rx Key Concepts• Two key concepts:Two key concepts:

• Intracranial pressureIntracranial pressure• Elevated when ICP >20 mm HgElevated when ICP >20 mm Hg

• Cerebral perfusion pressureCerebral perfusion pressure• CPP=MAP-ICPCPP=MAP-ICP• Must maintain CPP > 70 mm HgMust maintain CPP > 70 mm Hg• Example: MAP = 100, ICP = 20Example: MAP = 100, ICP = 20• CPP in above example = 80 mmHgCPP in above example = 80 mmHg


Increased ICP TreatmentIncreased ICP Treatment• Intracranial Pressure (ICP): Intracranial Pressure (ICP):

considered a major contributor to considered a major contributor to mortality when elevatedmortality when elevated

• Controlling ICP is considered Controlling ICP is considered essentialessential• OsmotherapyOsmotherapy• HyperventilationHyperventilation• Barbiturate comaBarbiturate coma


OsmotherapyOsmotherapy• Osmotherapy-MannitolOsmotherapy-Mannitol

• Reduces cerebral edema by Reduces cerebral edema by decreasing cerebral fluid volumedecreasing cerebral fluid volume

• Rebound effect-use less than 5 daysRebound effect-use less than 5 days• 20% solution20% solution• 0.5-1.0 g/kg/dose maintain serum 0.5-1.0 g/kg/dose maintain serum

osmolarity 310-320 mOsm/Losmolarity 310-320 mOsm/L


HOB ElevationHOB Elevation• Elevate head of bed-decrease ICPElevate head of bed-decrease ICP• Mechanical-helps drain blood by Mechanical-helps drain blood by

gravitygravity• Does not allow blood to pool in Does not allow blood to pool in

cranium, which may occur if patient cranium, which may occur if patient is left laying flatis left laying flat


Endotracheal IntubationEndotracheal Intubation• Intubation-not required, but airway Intubation-not required, but airway

protection and adequate ventilation protection and adequate ventilation are necessaryare necessary• Rely on clinical suspicion, not GCSRely on clinical suspicion, not GCS• Hyperventilation decreases ICP Hyperventilation decreases ICP • pCO2 should be kept around 30-35pCO2 should be kept around 30-35• Beneficial effect of sustained Beneficial effect of sustained

hyperventilation is not provenhyperventilation is not proven


ParalyticsParalytics• Recommended in order to prevent Recommended in order to prevent

increasing intrathoracic and venous increasing intrathoracic and venous pressures associated with pressures associated with coughing, suctioning, and bucking coughing, suctioning, and bucking on ETT, all of which may cause ICP on ETT, all of which may cause ICP spikesspikes

• ICP spikes associated with poorer ICP spikes associated with poorer outcome, especially in setting of outcome, especially in setting of elevated ICPelevated ICP


ICP MonitorsICP Monitors• Recommendatins ICP monitoring Recommendatins ICP monitoring

in patients with a GCS less than 9 in patients with a GCS less than 9 and all patients whose condition and all patients whose condition is thought to be deteriorating due is thought to be deteriorating due to elevated ICPto elevated ICP


BP ManagementBP Management• Lower blood pressure to decrease risk Lower blood pressure to decrease risk

of ongoing bleeding from ruptured of ongoing bleeding from ruptured small arteriessmall arteries

• Overaggressive treatment of blood Overaggressive treatment of blood pressure may decrease cerebral pressure may decrease cerebral perfusion pressure and worsen brain perfusion pressure and worsen brain injuryinjury

• Especially true with elevated ICPEspecially true with elevated ICP


BP ManagementBP Management• Recommendations that blood Recommendations that blood

pressure be maintained below a pressure be maintained below a mean arterial pressure of 130 mm mean arterial pressure of 130 mm Hg in persons with a history of Hg in persons with a history of hypertensionhypertension

• If there is an ICP monitor:If there is an ICP monitor:• ICP should be kept < 20 m HgICP should be kept < 20 m Hg• Cerebral perfusion pressure (MAP-Cerebral perfusion pressure (MAP-

ICP) should be kept > 70 mm HgICP) should be kept > 70 mm Hg


BP ManagementBP Management• Avoid hypotensionAvoid hypotension

• If systolic BP drops to less than If systolic BP drops to less than 90 mmHg, consider judicious fluid 90 mmHg, consider judicious fluid boluses and/or start pressorsboluses and/or start pressors


BP ManagementBP Management• Treatment should be started within Treatment should be started within

6 hours of symptom onset6 hours of symptom onsetLabetalolLabetalol

• 20 mg IV, followed by 40-80 mg IV q10 20 mg IV, followed by 40-80 mg IV q10 minmin

• Titrate BP or max 300 mgs adminTitrate BP or max 300 mgs admin• NiprideNipride• 0.5-1.0 mics/kg/min0.5-1.0 mics/kg/min


Fever ManagementFever Management• Elevated temperatures can increase the Elevated temperatures can increase the

degree of ischemic injury. degree of ischemic injury. • Etiologies include infection, neuronal Etiologies include infection, neuronal

injuryinjury• Studies have demonstrated increased Studies have demonstrated increased

morbidity and mortality in patients with morbidity and mortality in patients with sustained temperature elevation. sustained temperature elevation.

• Treat temperture > 38.5Treat temperture > 38.5˚̊ C C• Acetaminophen or a cooling blanket best Acetaminophen or a cooling blanket best

options. options.


Seizure TherapySeizure Therapy• Neuronal injury may lead to seizuresNeuronal injury may lead to seizures• Nonconvulsive seizures may contribute Nonconvulsive seizures may contribute

to coma in up to 10% of neurocritical to coma in up to 10% of neurocritical patientspatients

• Consider prophylactic antiepileptic Consider prophylactic antiepileptic therapy in setting of ICHtherapy in setting of ICH• Lobar hemorrhage-35% seizure rateLobar hemorrhage-35% seizure rate

• Fosphenytoin or phenytoinFosphenytoin or phenytoin


Medical TherapyMedical Therapy• EuvolemiaEuvolemia

• Isotonic crystalloid solutionsIsotonic crystalloid solutions• Electrolyte abnormalitiesElectrolyte abnormalities

• Correct deficitsCorrect deficits• Acid/base disordersAcid/base disorders

• Correct them if presentCorrect them if present• Steroids-no benefit??Steroids-no benefit??• Nimodipine ??Nimodipine ??


Blood ClotBlood Clot


ICH Surgical IndicationsICH Surgical Indications• Cerebral Hm ~5cm or (50mm3) or Cerebellar Cerebral Hm ~5cm or (50mm3) or Cerebellar

hemorrhage > 3 cm (30mm3) who are hemorrhage > 3 cm (30mm3) who are deteriorating or with brain stem deteriorating or with brain stem compression and hydrocephalus from compression and hydrocephalus from ventricular obstructionventricular obstruction

• Vascular malformation if lesion is surgically Vascular malformation if lesion is surgically accessible and patient has chance for good accessible and patient has chance for good outcomeoutcome

• Young patients with a moderate or large Young patients with a moderate or large lobar hemorrhage who are clinically lobar hemorrhage who are clinically deterioratingdeteriorating


Non-Surgical ICH PtsNon-Surgical ICH Pts• Small Hemorrhages (10 cmSmall Hemorrhages (10 cm33))• Minimal neurological deficitsMinimal neurological deficits• GCS < 4 (excluding cerebellar GCS < 4 (excluding cerebellar

hemorrhage with brain stem hemorrhage with brain stem compression)compression)


Key Learning PointsKey Learning Points• ICH is a dynamic, not a static processICH is a dynamic, not a static process• Hemorrhage volume can increase over timeHemorrhage volume can increase over time• CT scan is the most important tool in your CT scan is the most important tool in your

diagnostic toolboxdiagnostic toolbox• Manage blood pressure, noting that guidelines Manage blood pressure, noting that guidelines

are variableare variable• Aggressively manage fever and seizuresAggressively manage fever and seizures• Consider hyperventilation and paralytics in Consider hyperventilation and paralytics in

setting of increased ICP and deteriorationsetting of increased ICP and deterioration


Key Learning PointsKey Learning Points• Most ICH patients are non-surgicalMost ICH patients are non-surgical• Consult your neurosurgeon earlyConsult your neurosurgeon early• Steroids-no benefit?Steroids-no benefit?• There are promising new therapies There are promising new therapies

such as Factor VII on the horizonsuch as Factor VII on the horizon

Medicine 5th year, 3rd lecture (Dr. Mohammed Tahir)

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Transcript of Medicine 5th year, 3rd lecture (Dr. Mohammed Tahir)