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Cerebral Hemorrhage

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Cerebral Hemorrhage. Galen V. Henderson, M.D. Brigham and Women ’ s Hospital Director, Neuroscience ICU Harvard Medical School. Disclosures. I have no industry relationships. Outline. Epidemiology Imaging Prognosis Neurogenic stress cardiomyopathy Subclinical seizures - PowerPoint PPT Presentation

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Cerebral HemorrhageGalen V. Henderson, M.D.Brigham and Womens HospitalDirector, Neuroscience ICU

Harvard Medical School

DisclosuresI have no industry relationshipsOutlineEpidemiologyImagingPrognosisNeurogenic stress cardiomyopathySubclinical seizuresHypertonic salineProtein complex concentratesNew treatmentsSignificance of cerebral hemorrhageICH represents 10 15% of all strokes

Twice as common as subarachnoid hemorrhage and just as deadly

Only 20% live independently at 6 months

Worldwide incidence: 1020 cases per 100,000 populationAmerican Heart Association. Heart Disease and Stroke Statistics2005 Update; Qureshi AI et al. N Engl J Med. 2001;344:1450-1460. Broderick JP et al. Stroke. 1999;30:905-915; Broderick JP et al. N Engl J Med. 1992;326:733-736.Broderick JP, et al. Stroke. 2007;38:1-23.Significance of cerebral hemorrhage30 day mortality rate 35-52%, half of deaths occur in the first 2 days

Mortality rate unchanged over the last 20 years

To date no therapies have shown benefit in randomized clinical trialsSurgical evacuationOsmotic diureticsGlucocorticoidsIntracerebral hemorrhage SubtypesPrimary HematomasMicrobleeds

SecondaryTumorsVascular malformationAneurysmsCoagulopathyTraumaIschemic stroke with trans.Drug useSubarachnoidAneurysmalNon-aneurysmal

Subdural hematoma

Epidural hematomaQureshi AI et al. N Engl J Med. 2001;344:1450-1460.Broderick JP, et al. Stroke. 2007;38:1-23.Most Common Sites of ICH

PonsCerebral lobesBasal gangliaThalamusCerebellum50% deep35% lobar10% cerebellum6% brainstemICH usually involves the cerebral lobes, basal ganglia, thalamus, pons, or the cerebellum. Deep, large hematomas may extend into the ventricles.1 Available at: http://www.strokecenter.org/pat/ich.htm. Accessed March 5, 2005.Early Hemorrhage Growth in Patients with ICH

NIHSS, National Institutes of Health Stroke Scale.Brott T et al. Stroke. 1997;28:1-5.Image courtesy T. Brott, MD.8The primary objective of a prospective observational study was to determine the proportion of patients with primary spontaneous ICH who experience ongoing intracerebral bleeding, as measured by serial computing tomography (CT) scanning during the first 20 hours after symptom onset.1 The study patients had putaminal, thalmic, or lobar hemorrhages. The study also examined whether early hemorrhage growth is associated with early neurologic deterioration, as measured by changes in scores on the Glasgow Coma Scale (GCS) and the National Institutes of Health Stroke Scale (NIHSS). Hemorrhage growth was defined as an increase in the volume of intraparenchymal hemorrhage of > 33% as measured by image analysis on the 1- and 20-hour CT compared with baseline CT scan. A 33% change in volume was considered to correspond with a 10% increase in diameter, a clear difference that can be viewed by the naked eye. The 33% increase also was considered to represent true hemorrhage growth and not variability in CT imaging.The mean time from symptom onset to baseline CT scan was 89 37 minutes. Growth in volume of parenchymal hemorrhage of > 33% occurred in 26% of patients between the baseline and 1-hour CT scans. An additional 12% of patients had > 33% between the 1-hour and the 20-hour CT scans. Thus, 38% of study patients had > 33% growth in the volume of parenchymal hemorrhage during the first 20 hours after the baseline CT scan. This image clearly demonstrates growth of a hematoma according to the CT scans at 2 hours and 6.5 hours. Importantly, hemorrhage growth within the first hour was significantly associated with clinical deterioration, as measured by changes between the baseline and 1-hour GCS and NIHSS scores. No baseline clinical or CT prediction of hemorrhage growth was identified.The authors concluded that substantial early growth in patients with ICH is common and is associated with neurologic deterioration. Recognition of symptoms in the very early stages is essential for improving chances of a favorable outcome with any intervention.

1. Brott T et al. Stroke. 1997;28:1-5.

Early Hemorrhage Growth in Patients with ICH103 patients scanned < 3 hours of onset38% experienced significant hematoma growth (> 33% increase in volume) 26% within 1 hour of baseline scan12% between 1- and 20-hour scanICH growth was associated with clinical deterioration on NIHSSIn patients with putaminal ICH, hematoma growth (> 33%) occurs early (shown)NIHSS, National Institutes of Health Stroke Scale.Brott T et al. Stroke. 1997;28:1-5.9The primary objective of a prospective observational study was to determine the proportion of patients with primary spontaneous ICH who experience ongoing intracerebral bleeding, as measured by serial computing tomography (CT) scanning during the first 20 hours after symptom onset.1 The study patients had putaminal, thalmic, or lobar hemorrhages. The study also examined whether early hemorrhage growth is associated with early neurologic deterioration, as measured by changes in scores of the GCS and the NIHSS. Hemorrhage growth was defined as an increase in the volume of intraparenchymal hemorrhage of > 33% as measured by image analysis on the 1- and 20-hour CT compared with baseline CT scan. A 33% change in volume was considered to correspond with a 10% increase in diameter, a clear difference that can be viewed by the naked eye. The 33% increase also was considered to represent true hemorrhage growth and not variability in CT imaging.The mean time from symptom onset to baseline CT scan was 89 37 minutes. Growth in volume of parenchymal hemorrhage of > 33% occurred in 26% of patients between the baseline and 1-hour CT scans. An additional 12% of patients had > 33% between the 1-hour and the 20-hour CT scans. Thus, 38% of study patients had > 33% growth in the volume of parenchymal hemorrhage during the first 20 hours after the baseline CT scan. The figure shown above represents patients with putaminal hemorrhages who had > 33% growth by 1-hour CT scan.Importantly, hemorrhage growth within the first hour was significantly associated with clinical deterioration, as measured by changes between the baseline and 1-hour GCS and NIHSS scores. No baseline clinical or CT prediction of hemorrhage growth was identified.The authors concluded that substantial early growth in patients with ICH is common and is associated with neurologic deterioration.1. Brott T et al. Stroke. 1997;28:1-5.

ICH VolumePowerful Determinant of 30-day Outcome Condition at 30 days (Oxford Handicap Scale)Broderick JP et al. Stroke. 1993;24:987-993.Good recovery with volume > 30 mL does not occur

10As shown by Brott et al, continued bleeding or rebleeding leads to expansion of the hematoma volume, particularly within the first few hours after symptom onset.1 Broderick et al demonstrated that hematoma volume determines patient outcome.2 This graph couples volume of ICH with outcome (according to the Oxford Handicap Scale). It is clear that the larger the volume of ICH, the worse the outcome.It appears that the threshold for hematoma volume is approximately 30 mL. Good recovery with hematoma volumes > 30 mL is no longer possible because of the direct tissue damage as well as secondary factors, which probably include inflammation, edema, intraventricular extension of hemorrhage, and hydrocephalus.1,3

Brott T et al. Stroke. 1997;28:1-5.Broderick JP et al. Stroke. 1993;24:987-993.Brown DL et al. N Engl J Med. 2005;352:828-830.

28 mL43 mLImage courtesy T. Brott, MD.Slide No. 12 As an example, a 15-mL change in the ICH (the difference in size between a ping pong ball and a golf ball) has a major impact on patient outcome. A patient with a hematoma the size of a ping pong ball has a greater chance of a better outcome than a patient with a hematoma the size of a golf ball.Hence, active intervention to stop the hematoma from growing in size could be very beneficial.

Goldstein, J. N. et al. Neurology 2007;68:889-894Contrast within the hematoma GRE Sequences and Cerebral Amyloid Angiopathy

Lobar HemorrhageMicrobleedsThe ICH Score ComponentsGCS score342512113150ICH volume, cm3>301 20-25 mm Hg for > 5 minutesDrain CSF via ventriculostomyElevate head of bedOsmotherapySedation, agitation and fever controlHyperventilationPressor therapy to maintain MAP and ensure CPPFor refractory intracranial HTNPhenobarbital/Hypothermia/Decompressive craniotomyOsmolality of IV fluidsFluidOsmolality (mOsm/kg)5% Dextrose 252Lactated ringers250-260Plasma2855% Albumin290Normal Saline 0.9%30825% Albumin3106% Hetastarch3102% Normal Saline6823% Normal Saline102525% Mannitol13757.5% Normal Saline23.4% Normal Saline24008008BWH NeuroICUProtocol for MannitolNa, BUN, Glu, Cr, Glu and osm1 hour prior to dosing mannitolCheck Na, BUN, Glu, OsmIs Osm > 310YesNoCalculate Osm GapAdminister mannitolIf gap < 10 & Na < 160Give mannitolIf gap > 10 or Na > 160Hold mannitol and notify HOOsm gap=measured osm-calculated osmCalculated Osm 2(Na)+BUN/2.8+Glu/18Early seizures after ICHClinically apparent seizures4% in 1st 24 hours; 8% in 1st monthPredictors: lobar location, small ICH volumeNo convincing effect on outcome

Electrographic seizures28-31% by continuous EEG over ~ 72 hoursPredictors; hematoma enlargement on 24-hr CTPeriodic discharges associated with poor outcomePassero et al, Epilepsia, 2002Vespa et al, Neurology, 2003Classen et al, Neurology, 2007Kilpatrick et, Arch Neurolgoy 1990Franke et al, JNNP, 1992ICH: Seizure ProphylaxisSeizure after ICH 10% have generalized tonic-clonic seizuresPassero S, et al, Epilepsia 2002;43:1175.OPTION: Prophylactic anticonvulsants for 7 days for patients with large ICH at risk for increased ICPICH: Non-Convulsive SeizuresContinuous EEG MonitoringStuporous or comatose patients with nonconvulsive seizures or SE detected only with cEEG

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