The Pathophysiology And Management Of Hemorrhagic Stroke

1. Continuous Medical Continuous Medical
EducationEducation
Department of Neurosurgery, HKL
14 February 2007

2. EPIDEMIOLOGYEPIDEMIOLOGY
For a patient who presents with the For a patient who presents with the abrupt onsetabrupt onset
of a new focal of a new focal neurological deficitneurological deficit : :
5% are seizure, tumour or psychogenic5% are seizure, tumour or psychogenic
95% are vascular95% are vascular
–15% haemorrhagic15% haemorrhagic
ICH, SAH, SDHICH, SAH, SDH
–85% ischaemic infarct85% ischaemic infarct
Unknown, lacunar, cardiogenic embolus, large Unknown, lacunar, cardiogenic embolus, large
artery cerebrovascular lesion, tandem arterial artery cerebrovascular lesion, tandem arterial
pathology,pathology, atherosclerotic plaques in the aortic atherosclerotic plaques in the aortic
archarch

3. EPIDEMIOLOGYEPIDEMIOLOGY
Incidence 12-15/100,000/yrIncidence 12-15/100,000/yr
Intracerebral hemorrhage (ICH) is more than Intracerebral hemorrhage (ICH) is more than
twice as common as subarachnoid hemorrhage twice as common as subarachnoid hemorrhage
(SAH)(SAH)
Much more likely to result in death or major Much more likely to result in death or major
disability than cerebral infarction or SAH disability than cerebral infarction or SAH
35% to 35% to 50%50% can be expected to die within the can be expected to die within the
first monthfirst month after bleeding after bleeding
Only Only 10% of patients are living independently10% of patients are living independently 1 1
month after the hemorrhagemonth after the hemorrhage
20% are independent at 6 months 20% are independent at 6 months

4. EPIDEMIOLOGYEPIDEMIOLOGY
Risk factorsRisk factors
–Advancing Advancing ageage and and hypertension hypertension are the most are the most
important risk factorsimportant risk factors
–Age : >after Age : >after 55, doubles55, doubles with each decade with each decade
–Gender : more common in Gender : more common in menmen
–Ethnic : More common among young and middle-ageEthnic : More common among young and middle-age
blacks than whites of similar ages blacks than whites of similar ages
More common in Asians compared to whitesMore common in Asians compared to whites
–Previous CVA increases risk by Previous CVA increases risk by 23:123:1
–Alcohol consumptionAlcohol consumption
–Drug abuseDrug abuse
–Liver dysfunctionLiver dysfunction

5. EPIDEMIOLOGYEPIDEMIOLOGY
Causes of Intracranial HaemorrhageCauses of Intracranial Haemorrhage
•Primary ( hypertensive ) intracerebral haemorrhagePrimary ( hypertensive ) intracerebral haemorrhage
•Ruptured saccular aneurysmRuptured saccular aneurysm
•Ruptured AVMRuptured AVM
•Haemorrhagic disorders ( leukaemia, aplastic anaemia, Haemorrhagic disorders ( leukaemia, aplastic anaemia,
anticoagulant therapy, haemophilia..)anticoagulant therapy, haemophilia..)
•Haemorrhage into brain tumoursHaemorrhage into brain tumours
•Septic embolismSeptic embolism
•Haemorrhagic infarctHaemorrhagic infarct
•Inflammatory diseases of blood vesselsInflammatory diseases of blood vessels
•Amyloidosis Amyloidosis

6. EPIDEMIOLOGYEPIDEMIOLOGY
Locations of haemorrhageLocations of haemorrhage
–Putamen, lenticular nucleus, internal capsule, globus Putamen, lenticular nucleus, internal capsule, globus
pallidus pallidus 50%50%
–Thalamus Thalamus 15%15%
–Pons Pons 10-15%10-15%
–Cerebellum Cerebellum 10%10%
–Cerebral white matter Cerebral white matter 10%10%
–Brain stem Brain stem 6%6%
Common Common arterial feedersarterial feeders of ICH of ICH
–Lenticulostriates – putaminalLenticulostriates – putaminal
–ThalamoperforatorsThalamoperforators
–Paramedian branches ofParamedian branches of the basilar artery the basilar artery

7. EPIDEMIOLOGYEPIDEMIOLOGY
Lobar haemorrhageLobar haemorrhage vs deep haemorrhage vs deep haemorrhage
–Haemorrhage into the occipital, temporal, frontal and Haemorrhage into the occipital, temporal, frontal and
parietal lobes as opposed to deep structures – BG, parietal lobes as opposed to deep structures – BG,
thalamus, infratentorial structuresthalamus, infratentorial structures
–More likely associated with More likely associated with structural abnormalitiesstructural abnormalities
–More common in patients with high alcohol consumptionMore common in patients with high alcohol consumption
–More benign outcomeMore benign outcome
–CausesCauses
Extension of deep haemorrhageExtension of deep haemorrhage
Cerebral amyloid angiopathyCerebral amyloid angiopathy
TraumaTrauma
Haemorrhagic transformationHaemorrhagic transformation
TumourTumour
AVM/aneurysmAVM/aneurysm

8. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Chronic hypertensionChronic hypertension stimulates the brain's stimulates the brain's
blood vessels to make gradual, blood vessels to make gradual, adaptive adaptive
changeschanges in an attempt to in an attempt to preserve the blood-preserve the blood-
brain barrier brain barrier
One gradual change that may develop is One gradual change that may develop is
lipohyalinosislipohyalinosis
Subintimal fibroblast proliferation occurs, with Subintimal fibroblast proliferation occurs, with
an accumulation of lipid-laden macrophages an accumulation of lipid-laden macrophages
and cholesterol deposits; this results in and cholesterol deposits; this results in
hyalinization and lipidosishyalinization and lipidosis of the blood vessels of the blood vessels
This process segmentally affects the This process segmentally affects the smaller smaller
penetrating arteriespenetrating arteries (<200 mm in diameter) (<200 mm in diameter)

9. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Plasma leakagePlasma leakage from persistently from persistently
elevated blood pressures also can elevated blood pressures also can
result in result in hyaline degenerationhyaline degeneration of the of the
cerebral blood vessels cerebral blood vessels
Arterial sclerosis and fibrinoid necrosisArterial sclerosis and fibrinoid necrosis
may occur, as well as focal aneurysmal may occur, as well as focal aneurysmal
dilatation (Charcot-Bouchard dilatation (Charcot-Bouchard
intracerebral microaneurysm)intracerebral microaneurysm)
HemorrhageHemorrhage may then arise from may then arise from
rupture of the Charcot-Bouchard rupture of the Charcot-Bouchard
aneurysms aneurysms

10. ManagementManagement
•CTCT of the head is the imaging procedure of of the head is the imaging procedure of
choice in the initial evaluation of suspected choice in the initial evaluation of suspected
ICHICH
•Angiography should be considered for all Angiography should be considered for all
patients patients without a clear cause of hemorrhagewithout a clear cause of hemorrhage
who are who are surgical candidatessurgical candidates, particularly , particularly
young, normotensive patients who are young, normotensive patients who are
clinically stable.clinically stable.
Angiography is Angiography is not requirednot required for older for older
hypertensive patients who have a hemorrhage hypertensive patients who have a hemorrhage
in the basal ganglia, thalamus, cerebellum, or in the basal ganglia, thalamus, cerebellum, or
brain stem and in whom CT findings do not brain stem and in whom CT findings do not
suggest a structural lesion suggest a structural lesion
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
(1999 American Heart Association )

11. 4. MRI and MRA are helpful and may obviate 4. MRI and MRA are helpful and may obviate
the need for contrast cerebral angiography in the need for contrast cerebral angiography in
selected patients. They should also be selected patients. They should also be
considered to look for considered to look for cavernous cavernous
malformationsmalformations in in normotensive patients with normotensive patients with
lobar hemorrhageslobar hemorrhages and and normal angiographicnormal angiographic
results who are surgical candidates results who are surgical candidates
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
(1999 American Heart Association )
ManagementManagement

12. ManagementManagement - Treatment - Treatment
MedicalMedical
SurgicalSurgical
There is a lack of proven medical or There is a lack of proven medical or
surgical treatment for ICHsurgical treatment for ICH
This has lead to great variation among This has lead to great variation among
physicians concerning both surgical and physicians concerning both surgical and
medical treatmentmedical treatment
Well-designed and well-executed Well-designed and well-executed
randomized treatment studies of ICH randomized treatment studies of ICH
are urgently neededare urgently needed

13. ManagementManagement - Treatment - Treatment
MedicalMedical
Airway and oxygenationAirway and oxygenation
Blood pressureBlood pressure
ICPICP
Fluid managementFluid management
Prevention of seizuresPrevention of seizures
Body temperatureBody temperature
Other issuesOther issues

14. ManagementManagement - Treatment - Treatment
Airway and oxygenationAirway and oxygenation
Although intubation is not required for Although intubation is not required for
all patients, all patients, airway protectionairway protection and and
adequate ventilationadequate ventilation are critical are critical
Patients who exhibit a decreasing level Patients who exhibit a decreasing level
of consciousness or signs of of consciousness or signs of brain stem brain stem
dysfunctiondysfunction are candidates are candidates
Intubation should be guided by Intubation should be guided by
imminent respiratory insufficiency imminent respiratory insufficiency
rather than an arbitrary cutoff such as a rather than an arbitrary cutoff such as a
specific Glasgow Coma Scale (GCS) specific Glasgow Coma Scale (GCS)
score score
“Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
by the American Heart Association 1999

15. ManagementManagement - Treatment - Treatment
Indications for intubationIndications for intubation
–hypoxiahypoxia (pO2 (pO2 <60<60 mm Hg or PCO2 mm Hg or PCO2 >50>50 mm mm
Hg) Hg)
–risk of aspirationrisk of aspiration with or without with or without
impairment of arterial oxygenationimpairment of arterial oxygenation
AllAll patients with endotracheal tubes patients with endotracheal tubes
receive receive nasogastric or orogastric tubesnasogastric or orogastric tubes
to prevent aspiration and are monitored to prevent aspiration and are monitored
for for cuff pressure every 6 hourscuff pressure every 6 hours
Endotracheal tubes with soft cuffs can Endotracheal tubes with soft cuffs can
generally be maintained for 2 weeks generally be maintained for 2 weeks
“Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
by the American Heart Association 1999

16. ManagementManagement - Treatment - Treatment
In the presence of prolonged coma In the presence of prolonged coma
or pulmonary complications, or pulmonary complications,
elective tracheostomyelective tracheostomy should be should be
performed after 2 weeks performed after 2 weeks
OxygenOxygen should be administered to should be administered to
allall patients presenting with a patients presenting with a
possible ICH possible ICH
“Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
by the American Heart Association 1999

17. ManagementManagement - Treatment - Treatment
Blood PressureBlood Pressure
Optimal level of a patient's blood pressure Optimal level of a patient's blood pressure
should be based on individual factors should be based on individual factors
–Chronic Chronic hypertensionhypertension
–Raised Raised ICPICP
–CauseCause of haemorrhage of haemorrhage
The theoretical rationale for The theoretical rationale for lowering blood lowering blood
pressurepressure is to is to decreasedecrease the risk of on going the risk of on going
bleedingbleeding from ruptured small arteries and from ruptured small arteries and
arterioles arterioles
Conversely, over aggressive treatment of blood Conversely, over aggressive treatment of blood
pressure may pressure may decrease cerebral perfusiondecrease cerebral perfusion
pressure and theoretically pressure and theoretically worsenworsen brain injury brain injury
“Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
by the American Heart Association 1999

18. ManagementManagement - Treatment - Treatment
Blood pressure levels be maintained below a Blood pressure levels be maintained below a
mean arterial pressure of 130 mm Hgmean arterial pressure of 130 mm Hg in in
persons with a history of hypertension persons with a history of hypertension (level of (level of
evidence V, grade C recommendation)evidence V, grade C recommendation)
In patients with elevated ICP who have an ICP In patients with elevated ICP who have an ICP
monitor, monitor, cerebral perfusion pressurecerebral perfusion pressure (MAP–ICP) (MAP–ICP)
should be kept should be kept >70 mm Hg>70 mm Hg (level of evidence (level of evidence
V, grade C recommendation)V, grade C recommendation)
Mean arterial blood pressure Mean arterial blood pressure >110 mm Hg>110 mm Hg
should be should be avoidedavoided in the in the immediate immediate
postoperative periodpostoperative period
If systolic arterial blood pressure falls below 90 If systolic arterial blood pressure falls below 90
mm Hg, mm Hg, pressors pressors should be givenshould be given
“Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
by the American Heart Association 1999

19. Titrate from 0.05–0.2 µg · kg
-1
· min
-1
Norepinephrine
2–20 µg · kg
-1
· min
-1
Dopamine
2–10 µg · kg
-1
· min
-1
Phenylephrine
Volume replenishment is the first line of approach. Isotonic saline or colloids can be used and monitored with
central venous pressure or pulmonary artery wedge pressure. If hypotension persists after correction of volume
deficit, continuous infusions of pressors should be considered, particularly for low systolic blood pressure such as
<90 mm Hg.
Low blood pressure
4. If ICP monitoring is available, cerebral perfusion pressure should be kept at >70 mm Hg.
3. If systolic BP is <180 mm Hg and diastolic BP <105 mm Hg, defer antihypertensive therapy. Choice of
medication depends on other medical contraindications (eg, avoid labetalol in patients with asthma).
2. If systolic BP is 180 to 230 mm Hg, diastolic BP 105 to 140 mm Hg, or mean arterial BP 130 mm Hg on 2
readings 20 minutes apart, institute intravenous labetalol, esmolol, enalapril, or other smaller doses of easily
titratable intravenous medications such as diltiazem, lisinopril, or verapamil.
1. If systolic BP is >230 mm Hg or diastolic BP >140 mm Hg on 2 readings 5 minutes apart, institute nitroprusside.
0.625–1.2 mg Q 6 h as neededEnalapril
10–20 mg Q 4–6 hHydralazine
0.5–10 µg · kg
-1
· min
-1
Nitroprusside
500 µg/kg as a load; maintenance use, 50–200 µg · kg
-1
· min
-1
Esmolol
5–100 mg/h by intermittent bolus doses of 10–40 mg or continuous drip (2–8 mg/min)Labetalol
Elevated blood pressure

20. ManagementManagement - Treatment - Treatment
ICPICP
ICP may be managed through head position, ICP may be managed through head position,
osmotherapy, controlled hyperventilation, and osmotherapy, controlled hyperventilation, and
barbiturate comabarbiturate coma
Elevated ICP is defined as intracranial pressure Elevated ICP is defined as intracranial pressure
20 mm Hg for >5 minutes20 mm Hg for >5 minutes
A therapeutic goal for all treatment of elevated A therapeutic goal for all treatment of elevated
ICP is ICP is ICP <20 mm HgICP <20 mm Hg and cerebral perfusion and cerebral perfusion
pressure pressure (CPP) >70 mm Hg(CPP) >70 mm Hg
Patients with suspected elevated ICP and Patients with suspected elevated ICP and
deteriorating level of consciousness are deteriorating level of consciousness are
candidates for invasive ICP monitoring candidates for invasive ICP monitoring
“Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
by the American Heart Association 1999

21. ManagementManagement - Treatment - Treatment
In general, ICP monitors should be placed in In general, ICP monitors should be placed in
(but not limited to) patients with a GCS score (but not limited to) patients with a GCS score
of <9 and all patients whose condition is of <9 and all patients whose condition is
thought to be deteriorating due to elevated ICP thought to be deteriorating due to elevated ICP
(level of evidence V, grade C recommendation)(level of evidence V, grade C recommendation)
Ventricular drainsVentricular drains should be used in patients should be used in patients
with or at risk for hydrocephalus with or at risk for hydrocephalus
Because of infectious complications, external Because of infectious complications, external
drainage devices must be drainage devices must be checked regularlychecked regularly, ,
and duration of and duration of placement ideally should not placement ideally should not
exceed 7 daysexceed 7 days (level of evidence V, grade C (level of evidence V, grade C
recommendation)recommendation)
“Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”
by the American Heart Association 1999

22. ManagementManagement - Treatment - Treatment
Use of Use of anti-infectious prophylaxisanti-infectious prophylaxis is is
recommended (level of evidence V, grade C recommended (level of evidence V, grade C
recommendation) recommendation)
The beneficial effect of sustained The beneficial effect of sustained
hyperventilation on ICP is unresolved hyperventilation on ICP is unresolved
When hyperventilation is deemed no longer When hyperventilation is deemed no longer
necessary, necessary, gradual normalization of serum gradual normalization of serum
PCO2PCO2 should occur over a 24- to 48-hour should occur over a 24- to 48-hour
period period
In general, if hyperventilation is instituted for In general, if hyperventilation is instituted for
elevated ICP, PCO2 should be maintained elevated ICP, PCO2 should be maintained
between between 30 and 35 mm30 and 35 mm Hg until ICP is Hg until ICP is
controlledcontrolled

23. Emergency ICP therapyEmergency ICP therapy
–Comatose patient with clinical signs of Comatose patient with clinical signs of
brainstem herniationbrainstem herniation
Head up 30 degreeHead up 30 degree
Mannitol 20% 1-1.5gm/kgMannitol 20% 1-1.5gm/kg
Hyperventilation Pco2 30-35 mmHgHyperventilation Pco2 30-35 mmHg
–““Buy time” before a definitive Buy time” before a definitive
neurosurgical procedureneurosurgical procedure

24. Management of ICPManagement of ICP
OsmotherapyOsmotherapy
–The first medical line of defense is osmotherapy. However, The first medical line of defense is osmotherapy. However,
it it should not be used prophylacticallyshould not be used prophylactically. .
–Mannitol 20% (Mannitol 20% (0.25–0.5 g/kg every 4 h0.25–0.5 g/kg every 4 h) is reserved for ) is reserved for
patients with patients with type B ICP wavestype B ICP waves, progressively increasing , progressively increasing
ICP values, or clinical deterioration associated with mass ICP values, or clinical deterioration associated with mass
effect (level of evidence V, grade C recommendation). effect (level of evidence V, grade C recommendation).
–Due to its rebound phenomenon, mannitol is Due to its rebound phenomenon, mannitol is
recommended for only 5 d. recommended for only 5 d.
–To maintain an osmotic gradient, furosemide (10 mg Q 2–To maintain an osmotic gradient, furosemide (10 mg Q 2–
8 h) may be administered simultaneously with 8 h) may be administered simultaneously with
osmotherapy. osmotherapy.
–Serum osmolality should be measured twice daily in Serum osmolality should be measured twice daily in
patients receiving osmotherapy and targeted to 310 patients receiving osmotherapy and targeted to 310
mOsm/L.mOsm/L.

25. ManagementManagement of ICPof ICP
No steroidsNo steroids
–Corticosteroids in ICH are generally Corticosteroids in ICH are generally
avoided because multiple potential side avoided because multiple potential side
effects must be considered and clinical effects must be considered and clinical
studies have not shown benefit (level of studies have not shown benefit (level of
evidence II, grade B recommendation).evidence II, grade B recommendation).

26. Management of ICPManagement of ICP
HyperventilationHyperventilation
–Hypocarbia causes cerebral vasoconstriction. Hypocarbia causes cerebral vasoconstriction.
–Reduction of cerebral blood flow is almost Reduction of cerebral blood flow is almost
immediate, although peak ICP reduction may immediate, although peak ICP reduction may
take up to 30 minutes after pCO2 is changed. take up to 30 minutes after pCO2 is changed.
–Reduction of pCO2 to 35–30 mm Hg, best Reduction of pCO2 to 35–30 mm Hg, best
achieved by raising ventilation rate at constant achieved by raising ventilation rate at constant
tidal volume (12–14 mL/kg), lowers ICP 25% to tidal volume (12–14 mL/kg), lowers ICP 25% to
30% in most patients (levels of evidence III 30% in most patients (levels of evidence III
through V, grade C recommendation). through V, grade C recommendation).
–Failure of elevated ICP to respond to Failure of elevated ICP to respond to
hyperventilation indicates a poor prognosis.hyperventilation indicates a poor prognosis.

27. Management of ICPManagement of ICP
Muscle relaxantsMuscle relaxants
–Neuromuscular paralysis in combination with adequate Neuromuscular paralysis in combination with adequate
sedation can reduce elevated ICP by preventing increases sedation can reduce elevated ICP by preventing increases
in intrathoracic and venous pressure associated with in intrathoracic and venous pressure associated with
coughing, straining, suctioning, or "bucking" the ventilator coughing, straining, suctioning, or "bucking" the ventilator
(levels of evidence III through V, grade C (levels of evidence III through V, grade C
recommendation). recommendation).
–Nondepolarizing agents, such as vecuronium or Nondepolarizing agents, such as vecuronium or
pancuronium, with only minor histamine liberation and pancuronium, with only minor histamine liberation and
ganglion-blocking effects, are preferred in this situation ganglion-blocking effects, are preferred in this situation
(levels of evidence III through V, grade C (levels of evidence III through V, grade C
recommendation). recommendation).
–Patients with critically elevated ICP should be pretreated Patients with critically elevated ICP should be pretreated
with a bolus of a muscle relaxant before airway suctioning. with a bolus of a muscle relaxant before airway suctioning.
Alternatively, lidocaine may be used for this purpose.Alternatively, lidocaine may be used for this purpose.

28. Management of ICPManagement of ICP
Barbiturate ComaBarbiturate Coma
–Short acting thiopental 2-5 mg/kg slow stat then 1-5mg/Short acting thiopental 2-5 mg/kg slow stat then 1-5mg/
kg/hourkg/hour
–Decreased cerebral metabolism, decreased CBF and CBVDecreased cerebral metabolism, decreased CBF and CBV
–Beware of hypotensionBeware of hypotension
–Max reduction in cerebral metabolism is accompanied by Max reduction in cerebral metabolism is accompanied by
electrocerebral silenceelectrocerebral silence

29. ManagementManagement - Treatment - Treatment
Fluid ManagementFluid Management
The goal of fluid management is euvolemia The goal of fluid management is euvolemia
CVP should be maintained between 5 and 12 CVP should be maintained between 5 and 12
mm Hg or pulmonary wedge pressure at 10 to mm Hg or pulmonary wedge pressure at 10 to
14 mm Hg 14 mm Hg
Fluid balance is calculated by measuring daily Fluid balance is calculated by measuring daily
urine production and adding for insensible urine production and adding for insensible
water loss (urine output plus 500 mL for water loss (urine output plus 500 mL for
insensible loss plus 300 mL per degree in insensible loss plus 300 mL per degree in
febrile patients) febrile patients)
Electrolytes (sodium, potassium, calcium, and Electrolytes (sodium, potassium, calcium, and
magnesium) should be checked and magnesium) should be checked and
substituted according to normal values substituted according to normal values

30. ManagementManagement - Treatment - Treatment
Prevention of SeizuresPrevention of Seizures
Seizure activity can result in neuronal injury Seizure activity can result in neuronal injury
and destabilization of an already critically ill and destabilization of an already critically ill
patient and must be treated aggressively patient and must be treated aggressively
In patients with ICH, prophylactic antiepileptic In patients with ICH, prophylactic antiepileptic
therapy (preferably phenytoin with doses therapy (preferably phenytoin with doses
titrated according to drug levels [14 to 23 µg/titrated according to drug levels [14 to 23 µg/
mL]) may be considered for 1 month and then mL]) may be considered for 1 month and then
tapered and discontinued if no seizure activity tapered and discontinued if no seizure activity
occurs during treatment, although data occurs during treatment, although data
supporting this therapy are lacking (level of supporting this therapy are lacking (level of
evidence V, grade C recommendation)evidence V, grade C recommendation)

31. ManagementManagement - Treatment - Treatment
Body TemperatureBody Temperature
Body temperature should be maintained at Body temperature should be maintained at
normal levels normal levels
Acetaminophen 650 mgAcetaminophen 650 mg or cooling blankets or cooling blankets
should be used to treat hyperthermia >38.5° C should be used to treat hyperthermia >38.5° C
Febrile patients or those at risk for infection, Febrile patients or those at risk for infection,
appropriate cultures and smears (tracheal, appropriate cultures and smears (tracheal,
blood, and urine) should be obtained and blood, and urine) should be obtained and
antibiotics givenantibiotics given
NutritionNutrition
Enteral feeding should be started within 48h to Enteral feeding should be started within 48h to
reduce risk of malnutritionreduce risk of malnutrition

32. ManagementManagement - Treatment - Treatment
DVT preventionDVT prevention
–Dynamic compression stockings should be Dynamic compression stockings should be
placed on admissionplaced on admission
–Medications at day 2Medications at day 2
SC heparin 5000u bdSC heparin 5000u bd
LMW heparin enoxaparin 40 mg dailyLMW heparin enoxaparin 40 mg daily
No increased in intracranial bleedingNo increased in intracranial bleeding
Boeer A, Voth E, Henze T, Prange HW. Early heparin therapy in patients
with spontaneous intracerebral haemorrhage.
J Neurol Neurosurg Psychiatry 1991; 54: 466–67.

33. Reversal of coagulationReversal of coagulation
–Warfarin – increase risk of ICH 5-10XWarfarin – increase risk of ICH 5-10X
Reverse with FFP & Vit KReverse with FFP & Vit K
–Aim INR <1.4Aim INR <1.4
–Low molecule heparinLow molecule heparin
Reverse with protamine sulfate 1mg to 1 mg Reverse with protamine sulfate 1mg to 1 mg
enoxaparinenoxaparin

34. ManagementManagement - Treatment - Treatment
Other IssuesOther Issues
Many patients who are delirious or stuporous Many patients who are delirious or stuporous
are agitated are agitated
Prudent use of minor and major tranquilizers Prudent use of minor and major tranquilizers
is recommended is recommended
Short-acting benzodiazepines or propofol are Short-acting benzodiazepines or propofol are
preferred preferred
Pulmonary embolism is a common threat Pulmonary embolism is a common threat
during the recovery period, particularly for during the recovery period, particularly for
bedridden patients with hemiplegia. Pneumatic bedridden patients with hemiplegia. Pneumatic
devices decrease the risk of pulmonary devices decrease the risk of pulmonary
embolism during hospitalizationembolism during hospitalization
Depending on the patient's clinical state, Depending on the patient's clinical state,
physical therapy, speech therapy, and physical therapy, speech therapy, and
occupational therapy should be initiated as occupational therapy should be initiated as
soon as possible soon as possible

35. ManagementManagement - Treatment - Treatment
Surgical TreatmentSurgical Treatment
Management of cerebral haemorrhage - Management of cerebral haemorrhage -
Karolinska Stroke Update Consensus Karolinska Stroke Update Consensus
Statement 2004Statement 2004
As yet, an advantage of neurosurgical As yet, an advantage of neurosurgical
intervention over medical treatment has not intervention over medical treatment has not
been establishedbeen established

36. Surgical TreatmentSurgical Treatment
ICH Treatment TargetsICH Treatment Targets
• • Expanding hematomaExpanding hematoma
– – Local shear forcesLocal shear forces
– – Mass effectMass effect
–
↑
–
↑
Intracranial pressure (ICP)Intracranial pressure (ICP)
• • Local toxic effectsLocal toxic effects
– – Direct toxicity of blood productsDirect toxicity of blood products
– – EdemaEdema
– – ExcitotoxicityExcitotoxicity

37. ManagementManagement - Treatment - Treatment
Recently, three RCTs evaluating new Recently, three RCTs evaluating new
strategies for the treatment of the ICH strategies for the treatment of the ICH
have been completed.have been completed.
–a.     Early surgery versus initial conservative a.     Early surgery versus initial conservative
treatment in patients with spontaneous treatment in patients with spontaneous
supratentorial ICH (The International STICH supratentorial ICH (The International STICH
trial);trial);
–b.    Stereotactic aspiration combined with b.    Stereotactic aspiration combined with
instillation of fibrynolitic agent (The SICHPA instillation of fibrynolitic agent (The SICHPA
trial);trial);
–c.    Ultra-early haemostatic therapy by c.    Ultra-early haemostatic therapy by
using the recombinant activated factor VIIa using the recombinant activated factor VIIa
(The Novo-7 trial)(The Novo-7 trial)

38. Comparison between early surgery combined hematoma Comparison between early surgery combined hematoma
evacuation (within 24 hours of randomization) with medical evacuation (within 24 hours of randomization) with medical
treatment.treatment.
FINDINGS: FINDINGS: A total of 1,033 patients from 83 centers in 27 A total of 1,033 patients from 83 centers in 27
countries were randomized to early surgery (503) or initial countries were randomized to early surgery (503) or initial
conservative treatment (530). At 6 months, 51 patients were conservative treatment (530). At 6 months, 51 patients were
lost to follow-up, and 17 were alive with unknown status. lost to follow-up, and 17 were alive with unknown status.
Of 468 patients randomized to early surgery, 122 (26%) had Of 468 patients randomized to early surgery, 122 (26%) had
a favorable outcome compared with 118 (24%) of 496 a favorable outcome compared with 118 (24%) of 496
randomized to initial conservative treatment (odds ratio 0.89, randomized to initial conservative treatment (odds ratio 0.89,
95% confidence interval 0.66 –1.19, 95% confidence interval 0.66 –1.19, PP .414); absolute benefit .414); absolute benefit
2.3% (–3.2 to 7.7), relative benefit 10% (–13 to 33).2.3% (–3.2 to 7.7), relative benefit 10% (–13 to 33).
INTERPRETATION: INTERPRETATION: Patients with spontaneous Patients with spontaneous
supratentorial intracerebral hemorrhage in neurosurgical units supratentorial intracerebral hemorrhage in neurosurgical units
show no overall benefit from early surgery when compared show no overall benefit from early surgery when compared
with initial conservative treatment.with initial conservative treatment.
Early surgery versus initial conservative treatment in patients with
spontaneous supratentorial intracerebral haematomas in the
International Surgical Trial in Intracerebral Haemorrhage (STICH): a
randomized trial
Mendelow AD, Gregson BA, Fernandes HM, Murray GD,
Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH
investigators. Lancet 2005;365:387–97.

39. ManagementManagement - Treatment - Treatment
The results of SICHPA trialThe results of SICHPA trial ( ( Stereotatactic Stereotatactic
Treatment of Intracerebral Haematoma Treatment of Intracerebral Haematoma
by means of a Plasminogen Activatorby means of a Plasminogen Activator
The trial was prematurely stopped because of The trial was prematurely stopped because of
low recruitment. A cautious conclusion could low recruitment. A cautious conclusion could
be made that stereotactic aspiration of be made that stereotactic aspiration of
supratentorial hematoma after instillation of a supratentorial hematoma after instillation of a
plasminogen activator can be performed plasminogen activator can be performed
safely. It may reduce the hematoma volume safely. It may reduce the hematoma volume
significantly significantly

40. ManagementManagement - Treatment - Treatment
Main results of Novo-7 trial Main results of Novo-7 trial
Treatment with rFVIIa within 4 hours Treatment with rFVIIa within 4 hours
reduced hematoma expansion, reduced hematoma expansion,
decreased mortality, and improved decreased mortality, and improved
clinical outcome significantly, despite clinical outcome significantly, despite
slight increase in the risk of slight increase in the risk of
thromboembolic events. thromboembolic events.
A phase III trial is needed to confirm the A phase III trial is needed to confirm the
beneficial effect of rFVIIa in acute ICHbeneficial effect of rFVIIa in acute ICH
–FAST trial – phase 3
–Doses 20, 80 ug/kg
–Within 4 hour of ictus

41. Criteria for surgeryCriteria for surgery
AgeAge
Hematoma VolumeHematoma Volume
Location (Supra / Infratentorial)Location (Supra / Infratentorial)
ProgressionProgression
Timing of surgeryTiming of surgery

42. AgeAge
Predictive role in outcome and mortality rate in patients with ICHPredictive role in outcome and mortality rate in patients with ICH
1010
Age older than 60 years implies poor prognosis regardless of Age older than 60 years implies poor prognosis regardless of
treatmenttreatment
–Mortality rate (surgically treated): (Auer LM et al, J Mortality rate (surgically treated): (Auer LM et al, J
Neurosurgery, 1989)Neurosurgery, 1989)
<60 years old<60 years old25%25%
>60 years old>60 years old65%65%
The relationship between age and outcome more pronounced with The relationship between age and outcome more pronounced with
thalamic hemarrhagethalamic hemarrhage
1010
Patients with “rapidly progressive*” hematoma by serial CT scan, age Patients with “rapidly progressive*” hematoma by serial CT scan, age
older than 65 years was associated with 100% mortalityolder than 65 years was associated with 100% mortality
1010
•Patients who were obtunded or stuporous without herniation signs
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Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

43. Hematoma VolumeHematoma Volume
Volume of hematoma based on CT scan measurement is a strong Volume of hematoma based on CT scan measurement is a strong
predictor of functional outcome and death.predictor of functional outcome and death.
1010
[Volume = 4/3 x [Volume = 4/3 x ΠΠ x LWH ÷ 8 or LWH ÷ 2] x LWH ÷ 8 or LWH ÷ 2]
Broderick et JP, Brott TG, Duldner JE, et al: Volume of ICH: A Broderick et JP, Brott TG, Duldner JE, et al: Volume of ICH: A
powerful and easy-to-use predictor of 30-day mortality. Stroke powerful and easy-to-use predictor of 30-day mortality. Stroke
24:987-993, 199324:987-993, 1993
71%60%7%Lobar
93%64%23%Deep
>60cm330-60cm
3
<30cm3Mortality
10
Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

44. Hematoma VolumeHematoma Volume
Volpin et al, Neurosurgery (1984) retrospective reviewed of 132 Volpin et al, Neurosurgery (1984) retrospective reviewed of 132
patients with supratentorial ICH, patients with supratentorial ICH,
–those with hematoma volume >85cm3 have 100% mortality those with hematoma volume >85cm3 have 100% mortality
irrespective of treatmentirrespective of treatment
–Those with hematoma volume <26cm3, all survived without Those with hematoma volume <26cm3, all survived without
surgerysurgery
Large-volume thalamic hematoma are more devastating than similar Large-volume thalamic hematoma are more devastating than similar
sized subcortical or putaminal hematomassized subcortical or putaminal hematomas
1010
For infratentorial hematoma, all cerebellar hematoma greater than 3 For infratentorial hematoma, all cerebellar hematoma greater than 3
cm in diameter is recommended for surgerycm in diameter is recommended for surgery
1010
10
Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

45. ProgressionProgression
Broderick et al (1993) and Fujitsu K et al (1990) found that Broderick et al (1993) and Fujitsu K et al (1990) found that
rehemorrhage typically occurs within the first 6 hours of the primary rehemorrhage typically occurs within the first 6 hours of the primary
ictusictus
Deterioration occur later than 6 hours after hemorrhage can be Deterioration occur later than 6 hours after hemorrhage can be
contributed by other factors such as edema, hydrocephalus, new IVH contributed by other factors such as edema, hydrocephalus, new IVH
or metabolic abnormality.or metabolic abnormality.
Patients’ clinical severity at 6 hours most accurately represented the Patients’ clinical severity at 6 hours most accurately represented the
severity of the ictus:severity of the ictus:
–Fulminant Fulminant - Poor outcome despite treatment- Poor outcome despite treatment
–Rapidly progressiveRapidly progressive- outcome improved with hematoma - outcome improved with hematoma
evacuationevacuation
–Slowly progressive Slowly progressive - no significant difference in outcome based - no significant difference in outcome based
on treatmenton treatment
Fulminant = comatose, obtunded, herniation signs
Slowly progressive = lethargy at 6 hours

46. Timing of SurgeryTiming of Surgery
In the case of spontaneous ICH, earlier interventions would intuitively In the case of spontaneous ICH, earlier interventions would intuitively
appear superiorappear superior
Early evacuation of hematoma improves CBF, brain edema, ischemia, Early evacuation of hematoma improves CBF, brain edema, ischemia,
and outcome.and outcome.
It is supported by the following facts:It is supported by the following facts:
–50% death of patient with ICH occur within 48 hours of hemorrhage50% death of patient with ICH occur within 48 hours of hemorrhage
–Radiographic expansion or rebleeding occurs maximally within 3-4 Radiographic expansion or rebleeding occurs maximally within 3-4
hourshours
–Exacerbation occurs suddenly and most often within 4 to 6 hours of Exacerbation occurs suddenly and most often within 4 to 6 hours of
bleedingbleeding
–Secondary changes such as edema occur 7 to 8 hours after a Secondary changes such as edema occur 7 to 8 hours after a
hemorrhagehemorrhage

47. Timing of SurgeryTiming of Surgery
Brott T et al. Brott T et al. StrokeStroke. 1997; Early hemorrhage expansion is common. . 1997; Early hemorrhage expansion is common.
~1/3 of patients who present within 3 hours of symptom onset will ~1/3 of patients who present within 3 hours of symptom onset will
have substantial ICH expansionhave substantial ICH expansion

48. Timing of SurgeryTiming of Surgery
2
Neurosurg Focus 15 (4):Article 2, 2003, Update on management of intracerebral hemorrhage, NADER
POURATIAN, M.D., PH.D., NEAL F. KASSELL, M.D., AND AARON S. DUMONT, M.D.
Kaneko and colleagues[1983] also demonstrated superior outcomes Kaneko and colleagues[1983] also demonstrated superior outcomes
(relative to epidemiological data) when they reported a 6-month 7% (relative to epidemiological data) when they reported a 6-month 7%
mortality rate in a series of patients with 100 putaminal ICHs treated mortality rate in a series of patients with 100 putaminal ICHs treated
surgically within 7 hours of ictussurgically within 7 hours of ictus
Zuccarello M, Brott T, Derex, et al [1999] and Morgenstern LB, Zuccarello M, Brott T, Derex, et al [1999] and Morgenstern LB,
Frankowski RF, Shedden P, Pasteur W, Grotta JC; Surgical treatment for Frankowski RF, Shedden P, Pasteur W, Grotta JC; Surgical treatment for
intracerebral hemorrhage (STICH), [1998] are 2 pilot studies suggested intracerebral hemorrhage (STICH), [1998] are 2 pilot studies suggested
a benefit with early surgery (<12 hours) but were limited by small a benefit with early surgery (<12 hours) but were limited by small
numbers.numbers.
Morgenstern and colleagues[2001] showed that ultra-early surgery (that Morgenstern and colleagues[2001] showed that ultra-early surgery (that
is, 4 hours after ICH) is associated with increased re-hemorrhage and is, 4 hours after ICH) is associated with increased re-hemorrhage and
mortality rates mortality rates
A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours) A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours)
was stopped after interim analysis because of an increased rate of was stopped after interim analysis because of an increased rate of
rebleeding.2rebleeding.2

49. Timing of SurgeryTiming of Surgery
2
Neurosurg Focus 15 (4):Article 2, 2003, Update on management of intracerebral hemorrhage, NADER
POURATIAN, M.D., PH.D., NEAL F. KASSELL, M.D., AND AARON S. DUMONT, M.D.
Kaneko and colleagues[1983] also demonstrated superior outcomes Kaneko and colleagues[1983] also demonstrated superior outcomes
(relative to epidemiological data) when they reported a 6-month 7% (relative to epidemiological data) when they reported a 6-month 7%
mortality rate in a series of patients with 100 putaminal ICHs treated mortality rate in a series of patients with 100 putaminal ICHs treated
surgically within 7 hours of ictussurgically within 7 hours of ictus
Zuccarello M, Brott T, Derex, et al [1999] and Morgenstern LB, Zuccarello M, Brott T, Derex, et al [1999] and Morgenstern LB,
Frankowski RF, Shedden P, Pasteur W, Grotta JC; Surgical treatment for Frankowski RF, Shedden P, Pasteur W, Grotta JC; Surgical treatment for
intracerebral hemorrhage (STICH), [1998] are 2 pilot studies suggested intracerebral hemorrhage (STICH), [1998] are 2 pilot studies suggested
a benefit with early surgery (<12 hours) but were limited by small a benefit with early surgery (<12 hours) but were limited by small
numbers.numbers.
Morgenstern and colleagues[2001] showed that ultra-early surgery (that Morgenstern and colleagues[2001] showed that ultra-early surgery (that
is, 4 hours after ICH) is associated with increased re-hemorrhage and is, 4 hours after ICH) is associated with increased re-hemorrhage and
mortality rates mortality rates
A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours) A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours)
was stopped after interim analysis because of an increased rate of was stopped after interim analysis because of an increased rate of
rebleeding.2rebleeding.2

50. Patient’s selectionPatient’s selection
Significant consideration for surgical intervention is given in cases Significant consideration for surgical intervention is given in cases
involving younger patients (that is, those involving younger patients (that is, those < 60 years< 60 years of age) with of age) with
superficial hemorrhagessuperficial hemorrhages (particularly in the non-dominant (particularly in the non-dominant
hemisphere) in whom neurological status deteriorates after an hemisphere) in whom neurological status deteriorates after an
initially good presentationinitially good presentation
22
Patients with relatively normal consciousness (GCS Scores Patients with relatively normal consciousness (GCS Scores 13–1513–15) )
rarely require surgery, whereas deeply comatose patients (GCS rarely require surgery, whereas deeply comatose patients (GCS
Scores Scores 3–53–5) rarely benefit from surgery.) rarely benefit from surgery.
44
Surgery is therefore usually considered to have the most potential Surgery is therefore usually considered to have the most potential
benefit for the group of patients with GCS scores between benefit for the group of patients with GCS scores between 6 and 126 and 12
or in patients with deteriorating statusor in patients with deteriorating status
44
2
Neurosurg Focus 15 (4):Article 2, 2003, Update on management of intracerebral hemorrhage, NADER
POURATIAN, M.D., PH.D., NEAL F. KASSELL, M.D., AND AARON S. DUMONT, M.D.
4
Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E.
FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D

51. Patient’s selectionPatient’s selection
There is a neurosurgical bias toward more aggressive surgery for There is a neurosurgical bias toward more aggressive surgery for
nondominant hemispheric hemorrhages, although the authors of nondominant hemispheric hemorrhages, although the authors of
outcome studies have indicated that despite language disability outcome studies have indicated that despite language disability
associated with dominant hemispheric lesions, functional outcome is not associated with dominant hemispheric lesions, functional outcome is not
necessarily worse.necessarily worse.
44
Standard craniotomy for primary Standard craniotomy for primary brainstem or thalamic brainstem or thalamic
hemorrhageshemorrhages has been all but abandoned because of poor outcomes has been all but abandoned because of poor outcomes
44
Apparently successful cases of stereotactic aspiration of pontine Apparently successful cases of stereotactic aspiration of pontine
hematomas have been reported, but the effect on prognosis remains hematomas have been reported, but the effect on prognosis remains
unproven.unproven.
44
Kanaya and Kuroda [1992] recommended surgical treatment if the Kanaya and Kuroda [1992] recommended surgical treatment if the
hematoma volume was larger than 30 ml and the level of consciousness hematoma volume was larger than 30 ml and the level of consciousness
was somnolent to semicomatose.was somnolent to semicomatose.
4
Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review
MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF,
M.D

52. Summary of Guidelines Summary of Guidelines
for Removal of ICHfor Removal of ICH
Best therapy unclear
Young patients with a moderate or large lobar hemorrhage who are clinically deteriorating (levels of evidence II through
V, grade B recommendation).
3
.
ICH associated with a structural lesion such as an aneurysm, arteriovenous malformation, or cavernous angioma may
be removed if the patient has a chance for a good outcome and the structural vascular lesion is surgically accessible
(levels of evidence III through V, grade C recommendation).
2
.
Patients with cerebellar hemorrhage >3 cm who are neurologically deteriorating or who have brain stem compression
and hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible
(levels of evidence III through V, grade C recommendation).
1
.
Surgical candidates
Patients with a GCS score 4 (levels of evidence II through V, grade B recommendation). However, patients with a GCS
score 4 who have a cerebellar hemorrhage with brain stem compression may still be candidates for lifesaving surgery
in certain clinical situations.
2
.
Patients with small hemorrhages (<10 cm
3
) or minimal neurological deficits (levels of evidence II through V, grade B
recommendation).
1
.
Nonsurgical candidates
American Heart Association :
Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage, 1998

53. Surgical TechniquesSurgical Techniques
In 1903, Cushing first removed an intracerebral hematoma by In 1903, Cushing first removed an intracerebral hematoma by
craniotomycraniotomy
However operative mortality are high, ranging from 20-90%However operative mortality are high, ranging from 20-90%
Because of this, various less invasive methods of removal are Because of this, various less invasive methods of removal are
practised like simple aspiration, stereotactic aspiration, fibrinolytic practised like simple aspiration, stereotactic aspiration, fibrinolytic
treatment, mechanically assisted aspiration, and endoscopy.treatment, mechanically assisted aspiration, and endoscopy.
In particular circumstances, some of these techniques may be more In particular circumstances, some of these techniques may be more
efficacious for deep putaminal or thalamic hemorrhages. efficacious for deep putaminal or thalamic hemorrhages.
Others are beneficial for subcortical hematomas.Others are beneficial for subcortical hematomas.
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Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

54. Surgical TechniquesSurgical Techniques
The optimal surgical technique for hematoma evacuation is The optimal surgical technique for hematoma evacuation is not not
agreed uponagreed upon, although craniotomy remains the most common., although craniotomy remains the most common.
44
Traditional stereotaxy or frameless navigational systems, as well as Traditional stereotaxy or frameless navigational systems, as well as
intraoperative ultrasonographic guidance, allow more precise clot intraoperative ultrasonographic guidance, allow more precise clot
localization and minimization of injury to normal brainlocalization and minimization of injury to normal brain
44
Compared with craniotomy, minimally invasive techniques such as Compared with craniotomy, minimally invasive techniques such as
stereotactic or endoscopic clot evacuation may offer the potential for stereotactic or endoscopic clot evacuation may offer the potential for
a reduced incidence of surgery-related complications and improved a reduced incidence of surgery-related complications and improved
efficacy, but this has yet to be proven.efficacy, but this has yet to be proven.
44
4
Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review
MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF,
M.D.

55. CraniotomyCraniotomy
The The most widely used surgical interventionmost widely used surgical intervention in ICH is craniotomy and in ICH is craniotomy and
evacuation of the gross clot. evacuation of the gross clot.
This is a relatively invasive procedure associated with additional risks This is a relatively invasive procedure associated with additional risks
by subjecting patients to surgery, potential brain manipulation, and by subjecting patients to surgery, potential brain manipulation, and
anesthesia. anesthesia.
For putaminal hematoma, three general approaches have been used, For putaminal hematoma, three general approaches have been used,
ie ie transtemporal, transfrontal and transsylviantranstemporal, transfrontal and transsylvian, with preferred , with preferred
transcisternal-transsylvian-transinsular approach.transcisternal-transsylvian-transinsular approach.
Operating microscope is used routinely with bipolar coagulation, and Operating microscope is used routinely with bipolar coagulation, and
graduated sucker. graduated sucker.

56. CraniotomyCraniotomy
Avoid usage of Avoid usage of self-retaining retractorsself-retaining retractors as steady retraction is deleterious as steady retraction is deleterious
to brain parenchymal.to brain parenchymal.
The The center of hematoma is removed firstcenter of hematoma is removed first with the remaining marginal with the remaining marginal
clot then collapses and can likewise be evacuated.clot then collapses and can likewise be evacuated.
Particular attention to bleeding points and possible subtle pathologic Particular attention to bleeding points and possible subtle pathologic
findings such as small tumours, cryptic AVMs and carvenous angiomasfindings such as small tumours, cryptic AVMs and carvenous angiomas
All tissue is sent for histologic analysisAll tissue is sent for histologic analysis
Hemostasis is ensured by elevating systolic pressure temporarily to Hemostasis is ensured by elevating systolic pressure temporarily to
identify potential rebleeding sites. identify potential rebleeding sites.
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Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

57. CraniotomyCraniotomy
For large hematomas, For large hematomas, transcortical approachestranscortical approaches is evocated. is evocated.
Transtemporal approachTranstemporal approach is used if hematomas significantly extends is used if hematomas significantly extends
into the temporal lobeinto the temporal lobe
The general surgical principles for evacuating hematomas at other The general surgical principles for evacuating hematomas at other
locations, is corticotomies are placed locations, is corticotomies are placed near the epicanter of the ICHnear the epicanter of the ICH, ,
their length is minimized, eloquent tissue is avoided.their length is minimized, eloquent tissue is avoided.
For infratentorial hematomas, a For infratentorial hematomas, a suboccipitasuboccipital craniotomy is standard, l craniotomy is standard,
with paramedian incision, craniotomy rather craniectomy, and a with paramedian incision, craniotomy rather craniectomy, and a
ventriculostomy if hydrocephalus. ventriculostomy if hydrocephalus.
10
Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

58. Burr Hole AspirationBurr Hole Aspiration
Unpredictable consistency of hematomas makes aspiration difficult.Unpredictable consistency of hematomas makes aspiration difficult.
Experiementally, within one hour of clot genesis, 80% of the clot Experiementally, within one hour of clot genesis, 80% of the clot
becomes dense fibrous tissue.becomes dense fibrous tissue.
There is also a propensity to rebleed, which makes the lack of There is also a propensity to rebleed, which makes the lack of
visualization risker.visualization risker.
Niizuma et al (1989) study the result of stereotactic aspiration in 175 Niizuma et al (1989) study the result of stereotactic aspiration in 175
patients with putaminal hemorrhage, noted 75% had more than patients with putaminal hemorrhage, noted 75% had more than
50% of the clot removed and 7.4% had post-operative bleeding.50% of the clot removed and 7.4% had post-operative bleeding.
The low effectiveness and high rates of recurrence are major The low effectiveness and high rates of recurrence are major
limitation.limitation.
10
Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

59. Stereotactic AspirationStereotactic Aspiration
First used by Benes and coworkers in 1965 with limited success and First used by Benes and coworkers in 1965 with limited success and
only in only in 1978,1978, Backlund and Von Holst performed first successful Backlund and Von Holst performed first successful
stereotactic aspiration of an acute hemorrhage.stereotactic aspiration of an acute hemorrhage.
It has favourable outcome than craniotomy in It has favourable outcome than craniotomy in deep-seated lesionsdeep-seated lesions..
However, lack of direct visualization and the risk of rebleeding may However, lack of direct visualization and the risk of rebleeding may
limit this technique’s utility especially during the hyperacute phase of limit this technique’s utility especially during the hyperacute phase of
hemorrhage.hemorrhage.

60. Stereotactic Aspiration Stereotactic Aspiration
and Clot Lysisand Clot Lysis
In 1985, Niizuma et al reported a In 1985, Niizuma et al reported a CT-guided technique of hematoma CT-guided technique of hematoma
aspiration and lysis using urokinaseaspiration and lysis using urokinase..
Fibrinolysis is used to fascilitate clot dissolution by activating Fibrinolysis is used to fascilitate clot dissolution by activating
plasminogen, which dissolves fibrin.plasminogen, which dissolves fibrin.
Localization by direct-image projection on CT scanner with a radiopaque Localization by direct-image projection on CT scanner with a radiopaque
marker has approximately marker has approximately 5mm error5mm error compared to stereotaxy. compared to stereotaxy.
After localization, 3-4mm silicone tube is passed into the clot and After localization, 3-4mm silicone tube is passed into the clot and
hematoma is aspirated with a syringe repeatedly until no more clot is hematoma is aspirated with a syringe repeatedly until no more clot is
removed.removed.
Then a Dandy ventricular catheter is placed into the hematoma bed, and Then a Dandy ventricular catheter is placed into the hematoma bed, and
urokinase (urokinase (6000 U in 3 ml6000 U in 3 ml) is infused, repeated ) is infused, repeated two to four times a daytwo to four times a day
in 1 to 6 days until CT documents clot ressolution.in 1 to 6 days until CT documents clot ressolution.

61. Stereotactic Aspiration Stereotactic Aspiration
and Clot Lysisand Clot Lysis
Compared to t-PA, Compared to t-PA, urokinase is cheaper, longer half-life and has both urokinase is cheaper, longer half-life and has both
fibrinolytic and fibrinogenolytic activityfibrinolytic and fibrinogenolytic activity; dissolves existing clot and inhibit ; dissolves existing clot and inhibit
the formation of new clotthe formation of new clot
Additional risk isAdditional risk is rebleeding rebleeding. .
InfectiousInfectious complications of catheter placement and fibrinolysis vary complications of catheter placement and fibrinolysis vary
between between 0 and 5%.0 and 5%.
44
Findlay JM, Grace MG, Weir BK, Findlay JM, Grace MG, Weir BK, Neurosurgery;Neurosurgery; [1993] found that [1993] found that
thrombolytic agents have also been successfully used for hemorrhage in thrombolytic agents have also been successfully used for hemorrhage in
the ventricular systemthe ventricular system
4
Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review MATTHEW E.
FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF, M.D

62. Stereotactic Aspiration Stereotactic Aspiration
and Clot Lysisand Clot Lysis
Naff Naff et alet al. [Neurosurgery, 2004, Class I] randomized 48 patients with . [Neurosurgery, 2004, Class I] randomized 48 patients with
spontaneous IVH to receive placebo or 3 mg TPA injected every 12 spontaneous IVH to receive placebo or 3 mg TPA injected every 12
hours into the ventricle. hours into the ventricle. Clot resolution was faster in the TPA groupClot resolution was faster in the TPA group, ,
and there was a trend toward and there was a trend toward lower mortalitylower mortality, although bleeding , although bleeding
complications were greater in patients receiving TPA complications were greater in patients receiving TPA
Lee Lee et alet al. [. [Hong Kong Med JHong Kong Med J 2003 , Class III] reported on 29 2003 , Class III] reported on 29
patients with IVH treated with intraventricular streptokinase or patients with IVH treated with intraventricular streptokinase or
urokinase, and found that urokinase, and found that blood could be removed safelyblood could be removed safely (infection (infection
rate 3%, no bleeding) and effectively (shunt rate, 24%). rate 3%, no bleeding) and effectively (shunt rate, 24%).

63. Neuroendoscpic Neuroendoscpic
TechniquesTechniques
Endoscopy has not been used extensively to treat ICHEndoscopy has not been used extensively to treat ICH
This minimally invasive techniques designed to decrease hematoma This minimally invasive techniques designed to decrease hematoma
size while limiting surgical trauma.size while limiting surgical trauma.
In a study with 6 mm diameter neuroendoscope which was placed In a study with 6 mm diameter neuroendoscope which was placed
through a burr hole and guided by intraoperative ultrasonography. through a burr hole and guided by intraoperative ultrasonography.
The procedure was associated with The procedure was associated with good outcome where good outcome where
evacuation more than 50% in all patientsevacuation more than 50% in all patients with 45% patients with 45% patients
with more than 70% clot evacuated. There were no differences in with more than 70% clot evacuated. There were no differences in
outcome for putaminal or thalamic hemorrhage.outcome for putaminal or thalamic hemorrhage.
10
Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768

64. Neuroendoscpic Neuroendoscpic
TechniquesTechniques
Auer and colleagues (1989)found of all p;atients whom underwent Auer and colleagues (1989)found of all p;atients whom underwent
burr hole, neuroendoscopic navigation, and aspiration of hematoma, burr hole, neuroendoscopic navigation, and aspiration of hematoma,
those benefit of surgery with respect to QOL was limited to patients those benefit of surgery with respect to QOL was limited to patients
withwith lobar lobar hematomas and those hematomas and those younger than 60younger than 60 years of age. years of age.
Benefit may in fact be due to the Benefit may in fact be due to the reduced stressreduced stress provided by this provided by this
less invasive surgical procedure, with the persistent benefit of less invasive surgical procedure, with the persistent benefit of
reducing clot volume. reducing clot volume.
Longatti PL, Longatti PL, et al in et al in review of 13 patients having endoscopic removal review of 13 patients having endoscopic removal
of IVH at one institution during 7 years reported safe and successful of IVH at one institution during 7 years reported safe and successful
removal of blood with favorable outcome in 62% [removal of blood with favorable outcome in 62% [StrokeStroke 2004, Class 2004, Class
III].III].

65. Endoscopic Aspiration for Supratentorial ICH
Auer LM, Deinsberger W, Neiderkorn K, et al. Endoscopic surgery versus medial
treatment for spontaneous intracerebral hematoma: a randomized study. J
Neurosurg. 1989; 70: 530-535
•Inclusion Criteria: Patients with CT confirmed supratentiorial ICH > 10 cc and
< 48 hours from time of onset with altered level of consciousness.
•50 patients surgical group
•50 patients medical group
•Treatment: Endoscopic aspiration of clot
•Outcome: Mortality and disability at 6 months
Results:
74%58%
Poor
Outcome
70%42%Mortality
MedicalSurgical
Odds Ratio of Death and Dependency:
0.46 (0.20-1.04) surgery better

66. VentriculostomyVentriculostomy
Comatose patients in whom neurological status is severely impaired Comatose patients in whom neurological status is severely impaired
at baseline (GCS score < 9), at baseline (GCS score < 9), ICP monitoringICP monitoring, with the aid of either , with the aid of either
a fiberoptic intraparenchymal monitor or ventriculostomy, may be a fiberoptic intraparenchymal monitor or ventriculostomy, may be
considered. considered.
The advantage of the ventriculostomy is that it can also be used as a The advantage of the ventriculostomy is that it can also be used as a
therapeutictherapeutic means of reducing ICP. means of reducing ICP.
Adams RE, Diringer MN, Neurology. [1998] study the response to Adams RE, Diringer MN, Neurology. [1998] study the response to
external ventricular drainage in spontaneous intracerebral external ventricular drainage in spontaneous intracerebral
hemorrhage with hydrocephalus in 24 patients concluded that hemorrhage with hydrocephalus in 24 patients concluded that
external ventricular drains did not improve hydrocephalus, and external ventricular drains did not improve hydrocephalus, and
changes in ventricular volume did not correlate with changes in level changes in ventricular volume did not correlate with changes in level
of alertness of alertness

67. Surgical Evacuation of Surgical Evacuation of
Cerebellar ICHCerebellar ICH
There seems to be a general consensus regarding the role of surgery There seems to be a general consensus regarding the role of surgery
in patients with infratentorial hematomas. in patients with infratentorial hematomas.
44
This agreement exists despite that fact that there are no randomized This agreement exists despite that fact that there are no randomized
controlled trials evaluating surgical methods in posterior fossa SICH.controlled trials evaluating surgical methods in posterior fossa SICH.
44
Several series have reported good outcomes associated with surgical Several series have reported good outcomes associated with surgical
evacuation for patients with cerebellar hemorrhages evacuation for patients with cerebellar hemorrhages greater than 3 greater than 3
cmcm, or with , or with brainstem compressionbrainstem compression and and hydrocephalushydrocephalus..
44
4
Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review
MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF,
M.D.

68. Surgical Evacuation of Surgical Evacuation of
Cerebellar ICHCerebellar ICH
No evidence from randomized trials of benefits of surgical evacuation No evidence from randomized trials of benefits of surgical evacuation
in ICH.in ICH.
Evidence mostly in the form of case series. Evidence mostly in the form of case series.
Kobayaski S, Miyata A, Serizawa T, et al. Treatment of cerebellar Kobayaski S, Miyata A, Serizawa T, et al. Treatment of cerebellar
hemorrhage—surgical or conservative. Stroke. 1990; 21(8) Suppl: hemorrhage—surgical or conservative. Stroke. 1990; 21(8) Suppl:
I-62. I-62.
Design: Non-randomized Prospective Design: Non-randomized Prospective
Patients: 75 patients with Patients: 75 patients with cerebellar hemorrhagecerebellar hemorrhage were studied. were studied.
45 treated medically 45 treated medically
30 treated with decompressive surgery. 30 treated with decompressive surgery.
Patients with GCS < 13, and hematoma > 40 mmPatients with GCS < 13, and hematoma > 40 mm
Good outcome occurred Good outcome occurred 58%58% with surgery while only with surgery while only 18%18% with with
conservative medical therapy conservative medical therapy

69. Summary of Surgical Summary of Surgical
Treatment Treatment
RecommendationsRecommendations
44
Patients with small hemorrhages or minimal neurological deficit Patients with small hemorrhages or minimal neurological deficit
generally do well by undergoing generally do well by undergoing medical treatment alonemedical treatment alone..
Elderly patients in whom the GCS score is Elderly patients in whom the GCS score is less than 5less than 5 and those with and those with
brainstem hemorrhagesbrainstem hemorrhages also do also do not typically benefitnot typically benefit from surgery from surgery
Patients with Patients with cerebellar hemorrhages greater than 3 cmcerebellar hemorrhages greater than 3 cm in whom are in whom are
symptoms or neurological deterioration have occurred, or in whom symptoms or neurological deterioration have occurred, or in whom
brainstem compression and hydrocephalus are present, brainstem compression and hydrocephalus are present, should should
undergo evacuationundergo evacuation of the clot. of the clot.
Evacuation should be considered in patients with moderate- or large-Evacuation should be considered in patients with moderate- or large-
sized sized lobar hemorrhageslobar hemorrhages, those with , those with large-sized basal ganglialarge-sized basal ganglia
hemorrhages, and those exhibiting hemorrhages, and those exhibiting progressive neurological progressive neurological
deterioration.deterioration.
Ultra-earlyUltra-early removal of the hematoma by localized minimally invasive removal of the hematoma by localized minimally invasive
surgical procedures is promising surgical procedures is promising but unprovenbut unproven..
4
Neurosurg Focus 15 (4):Article 1, 2003, Spontaneous intracerebral hemorrhage: a review
MATTHEW E. FEWEL, M.D., B. GREGORY THOMPSON, JR., M.D., AND JULIAN T. HOFF,
M.D.

70. ICH Evaluation and TreatmentICH Evaluation and Treatment

71. FUTURE DIRECTIONSFUTURE DIRECTIONS
With the improved understanding of the pathophysiological changes With the improved understanding of the pathophysiological changes
that result in that result in hematoma expansionhematoma expansion, the development of , the development of cerebral cerebral
edemaedema, and the identity of , and the identity of hemoglobin degradation neurotoxinshemoglobin degradation neurotoxins will will
lead to more focused pharmacological treatments.lead to more focused pharmacological treatments.
Mayer SA [2003] has suggested there may be a role for ultra-early Mayer SA [2003] has suggested there may be a role for ultra-early
hemostatic therapy with hemostatic therapy with recombinant factor VIIarecombinant factor VIIa to prevent further to prevent further
hematoma expansion. hematoma expansion.
Best medical management has yet to be defined and may include Best medical management has yet to be defined and may include
future treatments of blood pressure and hypothermia, tight glucose future treatments of blood pressure and hypothermia, tight glucose
control, and selected use of glucocorticoids.control, and selected use of glucocorticoids.
Results from the STICH have provided important information about Results from the STICH have provided important information about
the utility of surgical evacuation of ICH but do not address questions the utility of surgical evacuation of ICH but do not address questions
about the timing, approach, and technique of other procedures.about the timing, approach, and technique of other procedures.

72. FUTURE DIRECTIONS FUTURE DIRECTIONS
-Stem cell therapy -Stem cell therapy
After the clot is removed, there is possibility of After the clot is removed, there is possibility of improving functional improving functional
outcome by using stem cellsoutcome by using stem cells to restore the damaged cerebral to restore the damaged cerebral
architecture.architecture.
Transplanted neural human stem cells have been shown to improve Transplanted neural human stem cells have been shown to improve
functional recovery in an animal model of ICH (Jeong SW, stroke, functional recovery in an animal model of ICH (Jeong SW, stroke,
2003)2003)
Nonaka M, Nonaka M, et al.et al.((Neurol ResNeurol Res 2004), had human neural stem cells 2004), had human neural stem cells
were injected intravenously 1 day after experimental ICH in rats. were injected intravenously 1 day after experimental ICH in rats.
After 2 months, stem cells had migrated to the After 2 months, stem cells had migrated to the perihematomal regionperihematomal region
where they where they differentiated into neurons and astrocytesdifferentiated into neurons and astrocytes. These animals . These animals
had better motor function compared with control subjectshad better motor function compared with control subjects

73. Hemostatic Therapy: Hemostatic Therapy:
Future? Future?
The lack of surgery-related benefit may suggest that The lack of surgery-related benefit may suggest that clot evacuation clot evacuation
after hematoma expansion is not beneficialafter hematoma expansion is not beneficial. .
Hemostatic therapyHemostatic therapy, however, is intended to stimulate clotting in , however, is intended to stimulate clotting in
individuals in whom the coagulation cascade is otherwise normal, to individuals in whom the coagulation cascade is otherwise normal, to
modify the evolution of the hematoma modify the evolution of the hematoma
Much attention has been given to Much attention has been given to factor VIIafactor VIIa, which promotes local , which promotes local
hemostasis at sites of vascular injury in patients with and without hemostasis at sites of vascular injury in patients with and without
coagulopathies.coagulopathies.

74. Supported by Levels III through V evidenceGrade C
Supported by Level II evidenceGrade B
Supported by Level I evidenceGrade A
Strength of
recommendation
Data from anecdotal case seriesLevel V
Data from nonrandomized cohort studies using historical controlsLevel IV
Data from nonrandomized concurrent cohort studiesLevel III
Data from randomized trials with high false-positive ( ) or high false-negative (ß) errorsLevel II
Data from randomized trials with low false-positive ( ) and low false-negative (ß) errorsLevel I
Level of evidence

75. Thank YouThank You