Review of Primary Intracerebral .Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics

  • View
    212

  • Download
    0

Embed Size (px)

Text of Review of Primary Intracerebral .Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics

Review of Primary

Intracerebral Hemorrhage

Rza Behrouz, DOAssistant Professor of Neurology

University of South Florida College of Medicine

85%ISCHEMIC

15%HEMORRHAGIC

STROKE

HEMORRHAGIC STROKE

1/3Subarachnoid

2/3Intracerebral

DEFINITION

Acute extravasation of blood into the brain

parenchyma

EPIDEMIOLOGY

More common in men

Subarachnoid hemorrhage more common in women

Risk increases dramatically with age

Risk doubles every 10 years after age 35

Mean age 60

2X in Blacks, Asians and Hispanics than Whites

Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics. May 2000: 19 (2): 419 -

438.Broderick JP et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke.

1999;30:905-915

EPIDEMIOLOGY

USprevalence

37,000

52,000

USannualdeathrate

20,000

USoverallannualcost $6Billion

Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics. May 2000: 19 (2): 419 -

438.Broderick JP et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke.

1999;30:905-915

Roosevelt

Lenin

Al-Sabah

Sharon

PRESENTATION

Sudden onset focal neurological deficit

85% during active

hours of the day

Smooth progression over time

TIAs unusual

Elevated blood pressure (90%)

Regardless of a pre-existing history of hypertension

Caplan LR. Intracerebral Hemorrhage.

Caplans Stroke: A Clinical Approach. Third Edition. 2000.Broderick JP et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke.

1999;30:905-915.

PRESENTATION

Nausea & emesis

~ 55 %

Early or abrupt change in LOC

~ 50 %

Headache ~ 40 %

Seizures

~ 10%

Caplan LR. Intracerebral Hemorrhage.

Caplans Stroke: A Clinical Approach. Third Edition. 2000.Broderick JP et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke.

1999;30:905-915.

PRIMARY SECONDARY

Unrelated to an underlying congenital or acquired brain lesions or

abnormalities

Related to

a pre-existing intracranial abnormality

Manno EM et al. Emerging Medical and Surgical Management Strategies in the Evaluation and Treatment of Intracerebral Hemorrhage. Mayo Clin Proc. March 2005;80(3):420-433.

PRIMARY HypertensionHypertensionCerebral Amyloid AngiopathyAnticoagulantsThrombolyticsDrug UseBleeding Diathesis

SECONDARYVascular MalformationsAneurysmsIntracranial NeoplasmCerebral InfarctionsVenous InfarctionMoyamoya DiseaseCerebral Vasculitis

Manno EM et al. Emerging Medical and Surgical Management Strategies in the Evaluation and Treatment of Intracerebral Hemorrhage. Mayo Clin Proc. March 2005;80(3):420-433.

Hypertension70%

AmyloidAngiopathy

20%

Anticoagulants (8%)

Drug Use

Bleeding Diathesis

HYPERTENSIVE HEMORRHAGE

HTN: the most important risk factor

Exact quantification of risk difficult to ascertain

Smoking and excessive alcohol can increase the risk

Treatment of HTN decreases risk of ICH by

~ 50%

Recurrent risk of HH is 1-2% per year

If blood pressure is well controlled

Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics. May 2000: 19 (2): 419 -

438.Hypertension Detection and Follow-up Program Cooperative Group. Five year findings.

JAMA

1982;247:633-8.

HYPERTENSIVE HEMORRHAGE

Rupture of deep-penetrating arteries

Originate from major cerebral arteries

Unprotected from direct effects of HTN

Diameter

100 -

600 m

Mayer SA et al. Treatment of intracerebral hemorrhage. Lancet Neurology

2005;4:662-72.

HYPERTENSIVE HEMORRHAGE

StriatumThalamus

Pons

Lobar

Cerebellum

HYPERTENSIVE HEMORRHAGE

Charcot -

Bouchard aneurysms

Not seen in all cases

Lipohyalinosis

More plausible explanation

Qureshi AI et al. Spontaneous Intracerebral Hemorrhage.

N Eng J Med.

Vol 344, No 19. May 10, 2001.Manno EM et al. Emerging Medical and Surgical Management Strategies in the Evaluation and Treatment of Intracerebral Hemorrhage. Mayo Clin Proc. March 2005;80(3):420-433.

AMYLOID ANGIOPATHY

Different than systemic amyloidosis

~ 20 % of ICH cases > 70

Risk with advancing age

Lobar or cortical

Multiple

Recurrent

Rate 5-15% per year

Less severe than HH

History of cognitive decline

Mayer SA et al. Treatment of intracerebral hemorrhage. Lancet Neurology

2005;4:662-72.

AMYLOID ANGIOPATHY

Diagnosis at autopsy

Lobar micro-hemorrhages

Most are clinically silent

Strongly suggests the diagnosis

Age > 70

History of lobar hemorrhage

Reflects disease severity and recurrence risk

Mayer SA et al. Treatment of intracerebral hemorrhage. Lancet Neurology

2005;4:662-72.

AMYLOID ANGIOPATHY

Beta/A4-amyloid in vessel Fluorescent stained wall unstained

Mayer SA et al. Treatment of intracerebral hemorrhage. Lancet Neurology

2005;4:662-72.

COAGULOPATHY

Warfarin

Increases risk 5 -

10 times

AR 0.3 -

1.7 % per year

Doubles the mortality of ICH

Aspirin

AR 0.2 % per year

Bleeding disorders

Mostly lobar

Hemorrhage develops gradually

Hart RG et al. Oral anticoagulants and intracerebral hemorrhage. Facts and hypotheses.

Stroke 1995. 26:1471-77.Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics. May 2000: 19 (2): 419 -

438.

COAGULOPATHY

Predictors for Warfarin-related ICHAge

Inadequate blood pressure control

Intense anticoagulation

Severe leukoareosis

Cerebral amyloid angiopathy

Hart RG et al. Oral anticoagulants and intracerebral hemorrhage. Facts and hypotheses.

Stroke 1995. 26:1471-77.Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics. May 2000: 19 (2): 419 -

438.

THROMBOLYTICS

6.4% with IV rTPA

NINDS tPA

study0.6 % with placebo (p

THROMBOLYTICS

Influential factorsNIHSS > 20

Age > 75

Edema and mass effect on baseline CT

Initial CT hypo-attenuation > 33% of MCA distribution

NINDS tPA

Study Group. Intracerebral

Hemorrhage After Intravenous t-PA Therapy for Ischemic Stroke. Stroke.

1997;28:2109-2118.Larrue

V et al. Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen

activator: a secondaryanalysis of the European-Australian Acute Stroke Study (ECASS II).

Stroke 2001 Feb;32(2):438-41.

DRUGS

1% of all cases

CulpritsCocaine, Amphetamines, Ephedrines

Mainly young patients

Predisposing factorsHypertension, AVM

Gebel JM et al. Intracerebral Hemorrhage. Neurologic Clinics. May 2000: 19 (2): 419 -

438.

DIAGNOSIS

Emergent diagnosisSize, volume and locationHydrocephalus / herniationIntraventricular extension

Door to CT< 25 min

Smith EE st al. Hemorrhagic Stroke.

Neuroimaging Clin of N Am.

15 (2005) 259-272.

DIAGNOSIS -

CT

Disappears Within 2 to 4 weeks

Severe anemia Reduces attenuation

Smith EE st al. Hemorrhagic Stroke.

Neuroimaging Clin of N Am.

15 (2005) 259-272.

DIAGNOSIS -

MRI

LimitationsTimePatient monitoring

RecommendedAlmost all patients with ICH

Structural abnormalities

Time course

Smith EE st al. Hemorrhagic Stroke.

Neuroimaging Clin of N Am.

15 (2005) 259-272.

ACUTE MANAGEMENT

!StopHemorrhage

Stabilize Hemodynamics

Complications

COAGULOPATHY

Successful reversal

INR < 1.4

Time is important

Early reversal of coagulopathy is critical

Mayer SA et al. Treatment of intracerebral hemorrhage. Lancet Neurology

2005;4:662-72.

COAGULOPATHY

Repeat INR in 4 hours Administer FFP if >1.4 -

otherwise every 6 hours

Vitamin K10 mg IV

FFP15 mL/kg

6 units

Mayer SA et al. Treatment of intracerebral hemorrhage. Lancet Neurology

2005;4:662-72.

COAGULOPATHY

Heparin reversalProtamine sulfate 10-50 mg IV over 1-3 minutesOR 1 mg for every 100 units of Heparin

Platelet transfusion4-8 unitsGoal platelet count > 100,000Use in ASA/Clopidogrel-related ICH controversial

Mayer SA et al. Treatment of intracerebral hemorrhage. Lancet Neurology

2005;4:662-72.

BLOOD PRESSURE

MAP

< 130 mmHg

With a history of hypertension

Ideally between 90 to 110 mmHgCPP > 70 mmHg

AgentsNicardipine (5-15 mg/hr), Labetolol (2-8 mg/min), EsmololHydralazine and Nitroprusside NOT recommended in acute ICH

Mayer SA et al. Optimizing blood pressure in neurological emergencies.

Neurocritical Care.

2004. 1: 287-99Broderick JP et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage.

Stroke.

1999;30:905-915

COMPLICATIONS

Hematom