Intracerebral Hemorrhage

Intracerebral Intracerebral HemorrhageHemorrhage

Marc Dorfman, MD, FACEP, MACPMarc Dorfman, MD, FACEP, MACP

EM Residency Program DirectorEM Residency Program Director

Resurrection Medical CenterResurrection Medical CenterChicago, ILChicago, IL

Marc Dorfman, MD, FACEP, MACP


Case PresentationCase Presentation

• 70 year old male70 year old male• Sudden onset, severe headacheSudden onset, severe headache• Took ASA for reliefTook ASA for relief• CollapsedCollapsed• Decreasing Mental StatusDecreasing Mental Status


Physical ExamPhysical Exam

• T-98.6 P-61 BP-201/96 RR-16T-98.6 P-61 BP-201/96 RR-16• Pupils-equal, sluggish, reactivePupils-equal, sluggish, reactive• CV-NSR, no murmurCV-NSR, no murmur• Skin-Bruise and flank from fallSkin-Bruise and flank from fall


More HistoryMore History

• Long standing HypertensionLong standing Hypertension• Unclear how well it was Unclear how well it was

controlledcontrolled• Postive-Tobbaco/AlcoholPostive-Tobbaco/Alcohol


Neurological ExamNeurological Exam

• Neurological exam:Neurological exam:• no gag reflex, withdraws to no gag reflex, withdraws to

pain, +4 DTR pain, +4 DTR


GCSGCS

• Eyes-0Eyes-0• Verbal-0Verbal-0• Motor-4Motor-4

NIH Stroke ScaleNIH Stroke Scale

NIH Stroke Scale


NIHSS ScoreNIHSS Score

• Stroke scale 38Stroke scale 38



Key Clinical QuestionsKey Clinical Questions• What is the epidemiology of ICH?What is the epidemiology of ICH?• What are the most common etiologies What are the most common etiologies

ICH?ICH?• What is the pathophysiology of ICH?What is the pathophysiology of ICH?• How does ICH present?How does ICH present?• Do patients with ICH present different Do patients with ICH present different

than Ischemic stroke patients?than Ischemic stroke patients?• Does hemorrhage volume and GCS Does hemorrhage volume and GCS

predict outcome?predict outcome?


Key Clinical QuestionsKey Clinical Questions

• How does hemorrhage volume How does hemorrhage volume increase over time?increase over time?

• What is the expected outcome What is the expected outcome of a patient with ICH?of a patient with ICH?


Mission StatementMission Statement• ICH is a cause of significant mortality and morbidity. ICH is a cause of significant mortality and morbidity.

Despite its established burden, considerably less Despite its established burden, considerably less investigative attention has been devoted to the study of investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the clinical studies have been performed to examine the surgical and medical managements of patients with ICH. surgical and medical managements of patients with ICH. No consistently efficacious strategies have been No consistently efficacious strategies have been identified in such investigations. Management of ICH identified in such investigations. Management of ICH unfortunately remains heterogeneous across institutions, unfortunately remains heterogeneous across institutions, and continues to suffer from the lack of proven medical and continues to suffer from the lack of proven medical and surgical effectiveness. and surgical effectiveness.

• THIS IS CHANGINGTHIS IS CHANGING

Update on management of intracerebral hemorrhage; Neurosurgery Focus 15; 2003 1-6


AlgorithmAlgorithm

Qureshi A, Tuhrim S: Spontaneous Intracerebral Hemorrhage; NEJM, Vol 344, No 19 May 10, 2001; 1450-1460


Intracranial HemorrhageIntracranial Hemorrhage• EpidemiologyEpidemiology• EtiologyEtiology• PathophysiologyPathophysiology


Stroke EpidemiologyStroke Epidemiology

Adapted from Scott PA, Barsan WG. Stroke, transient ischemic attack, and other central focal conditions.In: Tintinalli J. Emergency Medicine: A Comprehensive Study Guide. 5th ed. McGraw-Hill; 2000:1430.

Stroke

Hemorrhagic Stroke15-20%

Ischemic Stroke80-85%

Intracerebral Hemorrhage2/3

Subarachnoid Hemorrhage1/3


ICH-EpidemiologyICH-Epidemiology

• 10-15% of all strokes (80% 10-15% of all strokes (80% ischemic)ischemic)

• More common in men than womanMore common in men than woman• More common after 55 years of ageMore common after 55 years of age• Increased incidence in African Increased incidence in African

Americans, Japanese, and Hispanic Americans, Japanese, and Hispanic populationspopulations

Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005


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• 10% independent at 1 month10% independent at 1 month• One-fifth of survivors are One-fifth of survivors are

independent at 6 monthsindependent at 6 months• 7000 operations annually in 7000 operations annually in

USA to remove blood USA to remove blood

Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 199;30: 905-915


ICH Epidemiology-30 Day ICH Epidemiology-30 Day MortalityMortality

• Men 48%Men 48%• Woman 41%Woman 41%• African American 42%African American 42%• Lobar 39%Lobar 39%• Deep 45%Deep 45%• Pontine 44%Pontine 44%• Cerebellar 64%Cerebellar 64%

Broderick: Volume of ICH; Stroke Vol 24, No 7


EtiologyEtiology

• Primary ICH (78-88% cases)-Primary ICH (78-88% cases)-spontaneous rupture of small spontaneous rupture of small vessels damaged byvessels damaged by• Hypertension (basal ganglia, Hypertension (basal ganglia,

thalamus, pons, cerebellum)thalamus, pons, cerebellum)• Cerebral Amyloid AngiopathyCerebral Amyloid Angiopathy


EtiologyEtiology

• Pre-morbid Hypertension Pre-morbid Hypertension increases risk by 3.9%increases risk by 3.9%

• Improved control of Improved control of hypertension appears to reduce hypertension appears to reduce the incidence if intracerebral the incidence if intracerebral hemorrhagehemorrhage


Hypertensive ICHHypertensive ICH• HypertensionHypertension

• EssentialEssential• EclampsiaEclampsia• SympathomimeticsSympathomimetics

• CocaineCocaine• AmphetaminesAmphetamines• PhenylpropanolaminePhenylpropanolamine


EtiologyEtiology

• Cerebral Amyloid Angiopathy-Cerebral Amyloid Angiopathy-50% individuals greater than 80 50% individuals greater than 80 years oldyears old


EtiologyEtiology

• Low serum cholesterol (<160 Low serum cholesterol (<160 reason unknown)reason unknown)

• Alcohol consumptionAlcohol consumption• Previous ICH-especially lobar Previous ICH-especially lobar

hemorrhagehemorrhage


ICH EtiologiesICH Etiologies• TraumaTrauma• Vascular malformationVascular malformation

• AneurysmAneurysm• AvmAvm• Cavernous hemangiomasCavernous hemangiomas

• TumorTumor• CoagulopathyCoagulopathy• VasculitisVasculitis


PathophysiologyPathophysiology

• Primary-immediate effectsPrimary-immediate effects• Hemorrhage growthHemorrhage growth• Increased ICPIncreased ICP

• Secondary effectsSecondary effects• Downstream effectsDownstream effects• EdemaEdema• IschemiaIschemia



ICH Hemorrhage GrowthICH Hemorrhage Growth

• Several studies describe Several studies describe patients who had an increase in patients who had an increase in the volume of parenchymal the volume of parenchymal hemorrhage on repeat CT scanshemorrhage on repeat CT scans


ICH Hemorrhage VolumeICH Hemorrhage Volume• Old concept-Hemorrhage static Old concept-Hemorrhage static

process; bleeding complete in a process; bleeding complete in a minutesminutes

• New concept-Hemorrhage is New concept-Hemorrhage is dynamic; process continues for dynamic; process continues for several hoursseveral hours


ICH Volume GrowthICH Volume Growth


ICH Growth Study DesignICH Growth Study Design• 103 patients103 patients• CT scan baseline 1 and 20 hoursCT scan baseline 1 and 20 hours• Positive-increase hemorrhage 33%Positive-increase hemorrhage 33%• 38% patients with > 33% growth in 38% patients with > 33% growth in

volume of parenchymal hemorrhagevolume of parenchymal hemorrhage


ICH Volume GrowthICH Volume GrowthComparison of variables between Baseline and 1 hour CTs


ICH Growth Study ConclusionICH Growth Study Conclusion

• Substantial early hemorrhage growth in Substantial early hemorrhage growth in patients with with intracerebral patients with with intracerebral hemorrhage is common and is hemorrhage is common and is associated with neurological associated with neurological deterioration.deterioration.

• Randomized treatment trials are Randomized treatment trials are needed to determine whether this needed to determine whether this ongoing bleeding and frequent ongoing bleeding and frequent neurological deterioration can be neurological deterioration can be improvedimproved


ICH Hemorrhage GrowthICH Hemorrhage Growth

• Hematoma growth occurs in Hematoma growth occurs in patients with normal coagulation patients with normal coagulation profilesprofiles

• Hematoma enlargement is Hematoma enlargement is associated with a worse outcomeassociated with a worse outcome

• Hematoma growth occurs within the Hematoma growth occurs within the first few hours (up to 40% in the first first few hours (up to 40% in the first 3 hours) and is rare after 24 hours3 hours) and is rare after 24 hours



Hemorrhage Growth-PredictorsHemorrhage Growth-Predictors

• Initial Hematoma volumeInitial Hematoma volume• Early PresentationEarly Presentation• Irregular shapeIrregular shape• Liver diseaseLiver disease• HypertensionHypertension• HyperglycemiaHyperglycemia• Alcohol useAlcohol use• HypofibrinogenimaHypofibrinogenima



Hemorrhage Volume-MortalityHemorrhage Volume-Mortality• Volume graters 60 cm3Volume graters 60 cm3

• Deep-93%Deep-93%• Lobar-71%Lobar-71%

• Volumes 30-60 cm 3Volumes 30-60 cm 3• Deep-60%Deep-60%• Lobar-60%Lobar-60%• Cerebellar-75%Cerebellar-75%

• Volumes less 30 cmVolumes less 30 cm• Deep-23%Deep-23%• Lobar-7%Lobar-7%• Cerebellar-57%Cerebellar-57%

Broderick: Volume of ICH; Stroke Vol 24, No 7


Hemorrhage VolumeHemorrhage Volume

• Quick and dirty methodQuick and dirty method• ABC/2ABC/2

• A-greatest hemorrhage diameter by CTA-greatest hemorrhage diameter by CT• B-diameter 90 degrees to AB-diameter 90 degrees to A• C-approximate number of CT slices C-approximate number of CT slices

with hemorrhage multiplied by slick with hemorrhage multiplied by slick thickness in cmthickness in cm

L Schwamm; Guidelines for Emergency Department Management of Brain Hemorrhage 2, 2004


Secondary Effects of ICHSecondary Effects of ICH• Hematoma initiates edemaHematoma initiates edema• Edema is from osmotically active Edema is from osmotically active

proteins from the clotproteins from the clot• Vasogenic and cytotoxic edema lead to Vasogenic and cytotoxic edema lead to

disruption of blood brain barrier and disruption of blood brain barrier and death to neuronsdeath to neurons

• There may be unidentified secondary There may be unidentified secondary mediators of both neuronal injury and mediators of both neuronal injury and edema ( nuclear factor kappa-beta)edema ( nuclear factor kappa-beta)

Qureshi A, Tuhrim S: Spontaneous Intracerebral Hemorrhage; NEJM, Vol 344, No 19 May 10, 2001; 1450-1460


ICH-PresentationICH-Presentation• 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, vertigo, gaze paresisAtaxia, miosis, vertigo, gaze paresisAcute Evaluation and Management of Intracerebral Hemorrhage; Stroke 1996


ICH PresentationICH Presentation• Hypertension (90%)Hypertension (90%)• Altered mental status (50%)Altered mental status (50%)• Headache (40%) Headache (40%) • Vomiting (49%)Vomiting (49%)• Seizures (6-7%)Seizures (6-7%)


ICH-HypertensionICH-Hypertension

• Risk factor for bleedingRisk factor for bleeding• May promote rebleeding (logical May promote rebleeding (logical

but unproven)but unproven)• The big question-Will treating The big question-Will treating

hypertension promote ischemia hypertension promote ischemia or how low can we go?or how low can we go?


Altered Mental StatusAltered Mental Status

• Early decrease in level of Early decrease in level of consciousness seen about 50% consciousness seen about 50% patientspatients

• Uncommon finding in patients Uncommon finding in patients with ischemic strokewith ischemic stroke



HeadacheHeadache

• Occurs about 40% of patientsOccurs about 40% of patients• 17% with ischemic stroke17% with ischemic stroke



VomitingVomiting

• 49% ICH49% ICH• 2% Ischemic stroke2% Ischemic stroke• 45% with SAH45% with SAH



ICHICH CVACVA

Decrease Decrease LOCLOC

50%50% UncommonUncommon

HeadacheHeadache 40%40% 17%17%

VomitingVomiting 49%49% 2%2%


SeizureSeizure

• 28% of patients first 72 hours28% of patients first 72 hours• Mostly lobarMostly lobar

• Associated with Neurological Associated with Neurological worseningworsening

• Trend toward worse outcomeTrend toward worse outcome



PresentationPresentation

• Sudden onset of focal Sudden onset of focal neurological deficitneurological deficit

• Progresses over minutes to Progresses over minutes to hourshours

• Headache, N/V, Decreased LOC, Headache, N/V, Decreased LOC, Elevated BPElevated BP


ICH DiagnosisICH Diagnosis

• CT scanCT scan

CT scan is the most effective tool in the ED

CT scan is excellent for imaging blood


Poor Outcome Risk FactorsPoor Outcome Risk Factors

• Large or increasing volume of Large or increasing volume of hematomahematoma

• Low GCS on admissionLow GCS on admission• Interventricular clot extension Interventricular clot extension

and/or hydrocehalusand/or hydrocehalus• Anticoagulation agentsAnticoagulation agents• Relative edemaRelative edema

Update on management of intracerebral hemorrhage; Neurosurgery Focus 15; 2003 1-6


Poor Outcomes- Intraventricular Poor Outcomes- Intraventricular Extension HydrocephalusExtension Hydrocephalus

• Independent prognostic Independent prognostic indicatorindicator

• Important cause of neurological Important cause of neurological deteriorationdeterioration

• Location importance?Location importance?• Ventriculostomy-helpful?Ventriculostomy-helpful?



Outcome predictorOutcome predictor

• Initial GCSInitial GCS• Initial hematoma volumeInitial hematoma volume• If GCS < 9 and hematoma If GCS < 9 and hematoma

volume > 60 ml mortality at one volume > 60 ml mortality at one month 90%month 90%

• GCS > 9 and hematoma volume GCS > 9 and hematoma volume < 30 ml mortality > 17%< 30 ml mortality > 17%

Broderick, Brott; Volume if intracerebral hemorrhage: a powerful and easy-to-use predictor of 30 day mortality. Stroke

1993;24:987-93


ICH ScoreICH Score

• UCSFUCSF• GCS (3-4(2) 5-12(1) 13-15(0)GCS (3-4(2) 5-12(1) 13-15(0)• ICH volume >30(1) <30(0)ICH volume >30(1) <30(0)• IVH (yes, no)IVH (yes, no)• Infratentorial origin of ICH Infratentorial origin of ICH

(yes,no)(yes,no)• Age <80 yrs(0) or >80 yrs(1)Age <80 yrs(0) or >80 yrs(1)

Hemphill III, Bonovich: The ICH Score;Stroke,April 2001 891-896


ICH ScoreICH Score

• If score was six or greater all If score was six or greater all patients diedpatients died

• If score was zero all patients If score was zero all patients livedlived

Hemphill III, Bonovich: The ICH Score;Stroke,April 2001 891-896


ED Patient ManagementED Patient Management• Patient intubated in the EDPatient intubated in the ED• Stared on NicardapineStared on Nicardapine• BP-160/84 P-92 RR-VentedBP-160/84 P-92 RR-Vented• Eyes-Pupils fixedEyes-Pupils fixed• Patient expired within two hours Patient expired within two hours

of arrivalof arrival


Key Learning PointsKey Learning Points• ICH makes up only 10-15% strokesICH makes up only 10-15% strokes• ICH occurs in hypertensives greater then 55 yrs ICH occurs in hypertensives greater then 55 yrs

of ageof age• ICH presents differently than ischemic strokeICH presents differently than ischemic stroke• ICH volume expands over time-this is a marker ICH volume expands over time-this is a marker

for poor outcomefor poor outcome• One can risk stratify poor outcomes based on One can risk stratify poor outcomes based on

simple numbers such as GCS, hemorrhage simple numbers such as GCS, hemorrhage volumevolume

Questions??Questions??

[email protected]@ferne.org

Marc Dorfman, MDMarc Dorfman, [email protected]

773 792 7921773 792 7921

dorfman_ich_aaem_2005 2/12/2005 7:48 PMMarc Dorfman, MD, FACEP, MACP

http://www.ferne.org/

Documents

Intracerebral Hemorrhage