Nontraumatic Intracranial Hemorrhage: A Review and UpdateAdam Griffith MDDepartment of NeurosurgeryThe Permanente Medical Group

Introduction

What is it?

2nd most common subtype of stroke

Stroke is now the fifth leading cause of death overall.

The leading cause of disability in the U.S.

10-30/100,000

Any given year, there are >5 million cases and >3 million deaths secondary to ICH worldwide 50% of all fatal cases occurring in the 1st 48hrs

<40% of patients regain functional independence

ICH 2010 KP

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Learning Objectives and Outline

Etiology and Risk Factors

Presentation and Evaluation

Imaging and Workup

Management and Treatment Medical and Surgical

Anticoagulants/Antiplatelets

Case studies

Future

DISCLOSURE INFORMATION: The planners of this activity and the speaker, Adam Griffith, MD, do not have affiliations with any corporate organizations that may constitute a conflict of interest with this presentation.

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Important CME Information

Etiology and Risk Factors

Chronic HTN 50-70%

Cerebral amyloid angiopathy Older patients

Amyloid-β peptide and Apolipoprotein E

Coagulapathy-associated >15% of all cases

Antithrombotic/thrombolytic Congenital or acquired factor deficiencies

Underlying abnormality Aneurysm AVM Cerebral venous thrombosis and infarction

Tumors

Presentation

Presentation very similar to acute ischemic stroke

Sudden onset of a focal neurological deficit Certain clinical findings increase probability of ICH

Coma/decreased LOC, seizures accompanying deficit, DBP > 110, emesis, severe headache

Imaging

Neuroimaging CT +/- CTA +/- MRI(+/- MRA)

In hypertensive patients >65 with well-circumscribed hematoma located in BG/thalamus, the yield of CTA/MRI/MRA is low(2-3%), so decision not to proceed may be reasonable

If a patient has a small cerebellar infarct/small hemorrhage without mass effect and is comatose, then neurovascular studies are needed to exclude basilar artery occlusion

CTA and the “Spot sign”

DSA is the gold standard but with increasing accuracy, CTA is 95-100% accurate in determining secondary causes

Hematoma Location

Initial Management of ICH Airway – can patient protect airway? Is intubation needed?

CT head noncontrast

Consider CTA in selected cases

STAT labs including INR, platelet count, PTT

Emergent reversal of anticoagulant induced coagulopathy if patient is on warfarin or TSOAs (use “Neurosurgical Rapid Reversal of Coagulopathy” order set)

Blood pressure control

Intracranial pressure - are there clinical and/or radiographic signs of ICP elevation?

7 .

Initial Management of ICH - ICH expansion Occurs early (first 6 hours) and often

Seen in about 30-40% of patients in the first 24 hours

Seen in much higher % of patients if on anticoagulants

Amount of expansion and associated clinical decline is quite variable

The ‘ugly truth’ is that this can happen, research has not found a way to stop it, and that the care is essentially supportive

7 .

BP Management in ICH/SAH Tight control recommended for patients at risk of ICH/SAH

rebleeding such as AVM, aneurysm (typically SBP 100-150)

Super-tight control of BP not helpful (See below from ATACH-2; please note that study trial standard treatment was well below SBP 180)

In patients with suspected ICP (increased intracranial pressure), recommend discussing BP goal with Neurosurgery

7 .

Anticoagulant-associated ICH

Increasing use>>>currently a 3-fold increase in incidence of ICH Pts have increased risk for hematoma expansion and higher risk of death and

poor outcome

Warfarin 9-14% of all cases of ICH

Emergent Reversal of Warfarin Induced Coagulopathy

Vit K 10 mg IVK Centra (“high octane, concentrated

FFP on steroids”)For Jehovah’s witnesses, consider

recombinant Factor VII

7 .

***USE “Neurosurgical Rapid Reversal of Coagulopathy”

order set It has “everything” you need

Emergent Reversal of TSOA Induced Coagulopathy

For patients on dabigatran(direct thrombin inhibitor), use idarucizumab (Praxbind)

For patients on apixaban, rivaroxaban, edoxaban (oral direct Xainhibitors), use Kcentra

In the future, we anticipate FDA approval of andexanet alfa

***USE “Neurosurgical Rapid Reversal of Coagulopathy” order set

It has “everything” you need

7 .

How about ICH Patients on Antiplatelet therapy?

The only 1 randomized control trial to address platelet transfusion in ICH associated with antiplatelet use (PATCH – Platelet Transfusion in Cerebral Hemorrhage) showed no evidence of benefit and a trend toward harm

7 .

Platelet pheresis for all patients on dual antiplateletsPlatelet pheresis for all patients with symptomatic subdural hematomas on antiplatelet agentsUse of platelet pheresis products for low dose aspirin or NSAIDs for patients who need urgent neurosurgical procedures (EVD, burr holes, craniotomies)Others on a case by case basis

COMMENTS REGARDING PATCH TRIAL• Almost no patients in trial on dual antiplatelet agents• Patients in platelet transfusion group had higher mortality rates but there

were no significant platelet transfusion reactions to explain this• This study has not been replicated• No use of platelet function tests to determine presence/degree of

platelet dysfunction

Role of Surgical management

If hydrocephalus is present with or without intraventricularhemorrhage, a ventriculostomy is usually performed.

Decompressive suboccipital craniectomy (with or without ventriculostomy) should be strongly considered for cerebellar ICH > 3 cm in diameter.

In non-cerebellar hemorrhages, there is no evidence that surgical evacuation of ICH benefits patients. Two RCTs, STICH and STICH II, failed to find a benefit of surgical

hematoma evacuation by craniotomy compared to medical therapy.

7 .

Predicting Outcome of ICH:The ICH Score 0-6pt scale

GCS Given more weight as it was

found to be the strongest independent predictor

Age

ICH

IVH

Infratentorial ICH

Measuring ICH volume

Calculating ICH volume (AxBxC)/2

A = greatest hemorrhage diameter by CT B = diameter perpendicular to A C = approximate number of CT slices with hemorrhage

multiplied by the slice thickness in cm If a slice contains >75% of ICH area seen on the slice with the

greatest amount of ICH, it is counted as 1 slice If between 25 % and 75%, then as ½ slice If <25%, then it is not counted

ICH Volume and Intraventricular Hemorrhage

Both have strong independent associations with outcome

Hematoma Volume of 30ml is the cutoff Increased mortality

Worse functional outcome

Presence of IVH associated with a lower probability of favorable outcome

ICH score to help guide prognosis early on

Surgery rarely indicated(except for those requiring EVD placement for IVH and infratentorial hemorrhages)

Restarting Anticoagulants in Patients with ICH

Many factors are considered in making this decision, the most important one being the cause of ICH and expected risk of recurrence, and the patient’s risk of future thromboembolic events. For example: The risk of recurrence of ICH may be lower in non-lobar hemorrhages

versus lobar hemorrhages and with well-controlled hypertension.

In patients with a history of symptomatic ICH and atrial fibrillation with high risk estimation scores (such as > 5 on CHADS2), anticoagulation may still be an appropriate treatment option

7 .

Other issues/therapies

Na—no definite research showing appropriate level Normal sodium unless those cases when ICP is a concern150

Glucose—Target remains to be clarified—keep normal, avoid hypoglycemia

Temperature—avoid fever, keep <38; therapeutic cooling has not been systematically investigated in ICH pts

AEDs—clinical seizures should be treated EEG monitoring for those pts with decreased mental status out of proportion to

degree of brain injury

Prophylactic anticonvulsant medication should not be used

Case Studies

63yo M

Progressive headache over 3 days and left blurriness of vision

Left incomplete homonymous hemianopsia

CTA negative

6wk scan

77yo F on Coumadin for A fib along with other multiple medical problems

Presented with acute onset of confusion, headache, and left-sided hemiparesis

Long extended course in ICU and floor

Required readmission for respiratory failure

SNF, now in rehab

Ambulating with a walker for short distances

Required PEG initially but now eating on her own

47yo M

Acute speech disturbance, dense hemiparesis => unresponsive

Large left BG hemorrhage

GCS 4 on exam

Poor outcome

49yo M off HCTZ for a week p/w n/v

SBP >200

43yo M with ETOH abuse p/w headache, vomiting, ataxia

OR for EVD and decompression

Future

Reversal agent for factor Xa inhibitors

MISTIE-III trial

Minimally invasive surgical evacuation of deep hematomas

Summary

Noncontrast CT head scan +/- CTA If confirmed underlying vascular abnormality(eg aneurysm), then

decision with nsgy to transfer to Morse Ave for further care

SBP goal <150

Emergent reversal of anticoagulant induced coagulopathy if patient is on warfarin or TSOAs (use “Neurosurgical Rapid Reversal of Coagulopathy” order set

Prophylactic anticonvulsant medication should not be used

Role of surgical management limited(except for those with IVH and hydrocephalus requiring EVD placement and infratentorialhemorrhages)

Questions??

Works Cited

Aguilar, Maria and Thomas Brott. Update in Intracerebral Hemorrhage. The Neurohospitalist. 2011; 3: 148-159.

de Oliveira Manoel et al. Critical Care (2016) 20:272. DOI 10.1186/s13054-016-1432-0

Le Roux, P. et al. Race Against the Clock: Overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage. J Neurosurg. 2014; 121:1-20.

Morganstern, L. et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. (2010) 41:2108-2129. DOI 10.1161/STR.0b013e3181ec611b

Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009;373(9675):1632–44. doi:10.1016/S0140-6736(09)60371-8.

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