Intracerebral-Hemorrhage-ICH - ug 2024.pdf

Hemorragia intracerebral neurología

1. Intracerebral
Hemorrhage (ICH)

2. Acute Management of ICH
•Predicting hematoma expansion
•Preventing hematoma expansion
•Blood pressure control
•Reversing INR
•Platelet transfusion?
•Metabolic
•Monitoring for complications of ICH
•Seizures
•Hydrocephalus

3. 24-4812-240-3 6-123-6
hours from onset
Stroke 1996;27:1783-87
Is it expanding?

4. Spot sign
Wada et al., 2007

5. •Select CT slice with largest ICH
•A = longest axis (cm)
•B = longest axis perpendicular to A (cm)
•C = number of slices x slice thickness (cm)
A x B x C

Calculating ICH volume
2

6. ICH volume
> 30cc 1
< 30cc 0
Intraventricular extension
Yes 1
No 0
Infratentorial location
Yes 1
No 0
Age
> 80 1
< 80 0
Glasgow coma scale
3-4
5-12
13-15
2
1
0
Total score 0-6
Godoy, D. A. et al. Stroke 2006
Score30-day mortality
0 0%
1 13
2 26
3 72
4 97
5, 6 100
ICH score

7. Impact of intraventricular blood
_____
ICH =80 cc, GCS 8
……..
ICH =80 cc, GCS >8
__ __
ICH =20 cc, GCS 8
----- ICH =20 cc, GCS >8
Tuhrim et al. Crit Care
Med 1999;27:617-21

8. Preventing hematoma expansion
•Blood pressure control
•Reversing INR
•? Platelet transfusion
•Metabolic

9. Preventing Hematoma Expansion
•Blood Pressure Control

10. Target blood pressure 140 systolic?
INTERACT 2 trial
•Patients within 6 hours of onset of ICH
•Treatment arm: SBP <140
•Control arm: SBP <180

11. Systolic BP time trends
1 hour - Δ14 mmHg (P<0.0001)
6 hour - Δ14 mmHg (P<0.0001)
Intensive group to target (<140mmHg)
462 (33%) at 1 hour
731 (53%) at 6 hours
Mean Systolic Blood Pressure (mm Hg)
0
110
120
130
140
150
160
170
180
190
200
R153045606121824 2 3 4 5 6 7
Standard
Intensive
////
Minutes Hours Days / Time
164
153
150
139
am pmam pm am pm am pm am pm am pm
P<0.0001
beyond 15mins
Target level
INTERACT 2: results

12. Preventing Hematoma Expansion
•Reversing Anticoagulation

13. Reversing the INR
•No more fresh frozen plasma
•Choose prothrombin complex concentrate
•Kcentra
•Vitamin K dependent coagulation factors II, VII, IX, X and protein C+S
•Give vitamin K IV along with it

14. Heparin
•AHA Statement:
•Protamine Sulfate may be considered to reverse heparin in patients with
acute ICH (Class2b; Level of Evidence C)

15. AHA guidelines: ICH on heparin
•Protamine sulfate 1mg per 100 units heparin
•Dose decreases depending on time since IV heparin was stopped
•30-60 min: 0.5-0.75 mg/100 units heparin
•60-120 min: 0.375-0.5 mg/100 units heparin
•>120 min: 0.25 mg/100 units heparin
•Slow IV infusion, max rate 5 mg/min (high risk of severe hypotension if
faster)

16. Preventing Hematoma Expansion
•Platelet Transfusion

17. •282 ICH cases imaged at onset and at 72 hours, including 70 (25%) taking antiplatelet
medication
•No difference in baseline hematoma volume
•No difference in hematoma growth at 72 hours
•No difference in need for surgical evacuation
•No difference in Rankin score at 90 days
•No difference in mortality
Platelet transfusion for ASA use?

18. Platelet Transfusion
•AHA Statement:
•The usefulness of platelet transfusions in ICH patients with a history of
antiplatelet use is uncertain (class 2b: Level of Evidence C)
•Patients with a severe coagulation factor deficiency or severe
thrombocytopenia should receive appropriate factor replacement therapy or
platelets, respectively (class 1; Level of Evidence C)

19. •Used for hemophiliacs with Factor VIII antibodies
•FAST Trial
•Phase 3 trial of Factor VII for acute ICH (not on warfarin)
•Primary outcome: severe disability or death at 90 days
•821 patients randomized to placebo, 20, or 80 mcg/kg
•Treatment started within 4 hours of onset
NEJM 2008;358:2127-2137
Factor VII for acute ICH

20. Factor VII reduced ICH growth
•Reduced ICH growth with 80
mcg/kg vs placebo
•Time mattered: earlier treatment =>
less growth -6
-5
-4
-3
-2
-1
0
<2 hours<3 hours<4 hours
Hematoma
volume
(ml) vs
placebo

21. 90 day death/severe disability
•No clinical benefit
•MI and ischemic stroke
absolute risk increased 5%

22. Preventing Hematoma Expansion
•Metabolic

23. Metabolic
•Glucose should be monitored. Both hyperglycemia and hypoglycemia should
be avoided (class 1; Level C)
•Treatment of fever after ICH may be reasonable (class 2b; Level C)
•Systemic screening for MI with ECG and cardiac enzyme testing after ICH is
reasonable (class 2a; Level C)
•A formal dysphagia screen should be performed in all patients before
initiating oral intake to reduce pneumonia risk (class 1; Level B)

24. Complications of ICH
•Seizures
•Hydrocephalus
•DVT/PE

25. Seizures
•Prophylactic antiseizure medication is not recommended (class 3; Level B)
•Clinical Seizures should be treated with antiseizure meds (Class 1;Level A)
•Continuous EEG monitoring is probably indicated in ICH patients with
depressed mental status that’s out of proportion to degree of brain injury
(Class 2a; Level C) and should be treated with antiseizure meds if found to
have electrographic seizures on EEG (class 1; Level C)

26. Hydrocephalus

27. Clinical manifestations of Hydrocephalus
•Headache
•Vomiting
•Drowsiness → Coma

28. Indications for EVD
•EVD as treatment for hydrocephalus is reasonable, esp. in patients with
decreased level of consciousness (class 2a; Level B)

29. Steroids for ICH: NO!!!
•Single-center, double-blind randomized trial
•Dexamethasone versus placebo within 48 hours of onset for 9
days total
•Trial halted after enrollment of 93 patients due to high rate of
complications and no clinical benefit
NEJM 1987;316:1229-1233

30. DVT
•Risk of DVT in hemiplegic patients is 10-50% during acute hospitalization
•Intermittent pneumatic compression must be used immediately (class 1; Level A)
•Graduated compression stockings are not beneficial to reduce DVT or improve out
comes (class 3; Level A)
•After 1-4 days from onset LMW heparin or unfractionated heparin.

31. Intraventricular Hemorrhage
•Although intraventricular administration of rtPA in IVH appears to have a
fairly low complication rate, the efficacy and safety of this treatment are
uncertain (class 2b; Level B)
•The efficacy of endoscopic treatment of IVH is uncertain (class 2b; Level B)

32. STICH Trial
•Multicenter international randomized trial of early surgery versus medical
management for ICH
•Crossover to surgery possible, so NOT strictly a trial of surgery versus medicine
•Surgeon uncertain about benefit of surgery
•Randomization within 72 hours of ICH; surgery within 24 hours of randomization
•Supratentorial ICH only
•1033 patients randomized
Mendelow et al. Lancet 2005

33. STICH Results

34. Surgery
•Patients with cerebellar hemorrhage who are deteriorating neurologically or
have brain stem compression or hydrocephalus should under go surgical
removal as soon as possible (class 1; Level C)
•Initial treatment of these patients with ventricular drainage rather than
surgical evacuation is not recommended (class 3; Level C)
•For most patients with supratentorial ICH, usefulness of surgery is not well
established (class2b; Level A)

35. Surgery
•Policy of early hematoma evacuation is not clearly beneficial compared to
hematoma evacuation when patient deteriorates (Class 2b; Level A)

40. Angiopatia amiloidea

41. MAV Cerebral

43. Deep ICH is like lacunar infarct
•Deep ICH occurs in:
•Basal ganglia and thalamus
•Pons
•Cerebellum
•Pathology is similar to lacunar infarct
•Lipohyalinosis
•Charcot-Bouchard aneurysms—may be artifactual
•After deep ICH, annual risk of recurrence is: 2.1%
Neurology 2001;56:773-777

44. Cerebral amyloid angiopathy
•The most common risk factor for lobar ICH
•Infiltration of cortical vessels by amyloid protein
•Probable CAA: age>55with recurrent lobar ICH
•After a first lobar ICH, the 2-year cumulative incidence of a second ICH
is…
21%
N Engl J Med 2000;342:240-245

45. CAA-Boston Diagnostic
Criteria

46. ICH 30-Day Mortality: 30-50%