Spontaneous intracerebral hemorrhage

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Spontaneous intracerebral hemorrhage

Text of Spontaneous intracerebral hemorrhage

  • 1.SPONTANEOUS INTRACEREBRAL HEMORRHAGE: PROGNOSIS AND TREATMENT Pratap Sagar Tiwari , Internal Medicine, NGMC, Nepal

2. MORTALITY AND FUNCTIONAL OUTCOME The 30-day mortality from ICH ranges from 35 to 52 percent [1-8], one-half of these deaths occur within the first two days [3,7,9] 1.Anderson CS, Chakera TM, Stewart-Wynne EG, Jamrozik KD. Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989-90: incidence and outcome. J Neurol Neurosurg Psychiatry 1994; 57:936.2.Counsell C, Boonyakarnukul S, Dennis M, et al. Primary intracerebral hemorrhage in the Oxford-shire community Stroke Project. Cerebrovasc Dis 1995; 5:26.3.Broderick JP, Brott TG, Duldner JE, et al. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality.4.Fogelholm R, Murros K, Rissanen A, Avikainen S. Long term survival after primary intracerebral haemorrhage: a retrospective population based study. J Neurol Neurosurg Psychiatry 2005; 76:1534.5.Flaherty ML, Haverbusch M, Sekar P, et al. Long-term mortality after intracerebral hemorrhage. Neurology 2006; 66:1182.6.Sacco S, Marini C, Toni D, et al. Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Stroke 2009; 40:394.7.Zia E, Engstrm G, Svensson PJ, et al. Three-year survival and stroke recurrence rates in patients with primary intracerebral hemorrhage. Stroke 2009; 40:3567.8.van Asch CJ, Luitse MJ, Rinkel GJ, et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010; 9:167.9.Franke CL, van Swieten JC, Algra A, van Gijn J. Prognostic factors in patients with intracerebral haematoma. J Neurol Neurosurg Psychiatry 1992; 55:653.stroke 1993; 24:987. 3. MORTALITY AND FUNCTIONAL OUTCOME Furthermore, only a small number of patients function independently after the event. In a prospective study of 166 patients with spontaneous ICH from a large US metropolitan area, only 12 percent were normal or minimally handicapped at 30 days [1]. A systematic review estimated that between 12 and 39 percent of patients achieve independent function [2]. 1.Daverat P, Castel JP, Dartigues JF, Orgogozo JM. Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis. Stroke 1991; 22:1.2.van Asch CJ, Luitse MJ, Rinkel GJ, et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010; 9:167. 4. MODIFIED RANKIN SCALE ScoreDescription0No symptoms at all1No significant disability despite symptoms; able to carry out all usual duties and activities2Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance3Moderate disability; requiring some help, but able to walk without assistance4Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance5Severe disability; bedridden, incontinent and requiring constant nursing care and attention6Dead 5. MORTALITY AND FUNCTIONAL OUTCOME A study (SIVMS:90 vs OXVASC:60 )found that hemorrhage from a cerebral arteriovenous malformation were associated with a lower case-fatality rate, despite a similar hemorrhage volume and a higher admission GCS compared with spontaneous ICH(12 VS 61 %) [1]. Mortality was also reported to be low (1 of 22) in a cohort of children with ICH in whom vascular malformations was the identified etiology in 91 percent [2]. 1.van Beijnum J, Lovelock CE, Cordonnier C, et al. Outcome after spontaneous and arteriovenous malformation-related intracerebral haemorrhage: population-based studies. Brain 2009; 132:537.2.Beslow LA, Licht DJ, Smith SE, et al. Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study. Stroke 2010; 41:313. 6. LONG TERM MORTALITY AND FUNCTIONAL OUTCOME A retrospective cohort study identified 411 patients with 1st ever ICH and found that the annual risk of dying compared with controls was increased 4.5-fold during the 1st yr after ICH and 2.2-fold during years 2-6 [1]. A subsequent longitudinal prospective cohort study evaluated patients(n:140) who had survived the first 3 mnths after ICH and observed that mortality at 7yrs was significantly higher than controls(n:260) (32.9 vs 19.4 %) [2]. In a population-based cohort of patients(n:1224) hospitalized after ICH in the Greater Cincinnati/Northern Kentucky area, the 10yr survival was 18% [3] 1.Fogelholm R, Murros K, Rissanen A, Avikainen S. Long term survival after primary intracerebral haemorrhage: a retrospective population based study. J Neurol Neurosurg Psychiatry 2005; 76:1534.2.Saloheimo P, Lapp TM, Juvela S, Hillbom M. The impact of functional status at three months on long-term survival after spontaneous intracerebral hemorrhage. Stroke 2006; 37:487.3.Flaherty ML, Haverbusch M, Sekar P, et al. Long-term mortality after intracerebral hemorrhage. Neurology 2006; 66:1182. 7. What are the important prognostic factors ??? 8. PROGNOSTIC FACTORS Initial ICH volume and level of consciousness Hematoma growth Intraventricular extension Early neurologic deterioration Preceding antithrombotic use 1. Oral anticoagulants 2. Antiplatelets Limiting care and other factors 9. INITIAL ICH VOLUME AND LEVEL OF CONSCIOUSNESS In a study of 188 patients with ICH that analyzed predictors of 30day mortality [1]; the following observations were made: An ICH vol of 60 cm3 on initial CT and a GCS score of 8 predicted a 30-day mortality of 91 %. An ICH vol 10 mmol/L) [3]. 1.Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38:1655.2.Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007; 38:2001.3.European Stroke Initiative Executive Committee, EUSI Writing Committee, Olsen TS, et al. European Stroke Initiative Recommendations for Stroke Management-update 2003. Cerebrovasc Dis 2003; 16:311. 24. OTHER FACTORS: CHOLESTEROL /STATIN A study had found that low LDL cholesterol levels on admission were associated with increased mortality(n:88) [1]. Low total and LDL cholesterol have been linked to a risk of death in ICH. In one study of 108 patients with ICH, lower serum LDL-cholesterol predicted early hematoma growth, neurologic deterioration, and three-month mortality [2]. 1.Ramrez-Moreno JM, Casado-Naranjo I, Portilla JC, et al. Serum cholesterol LDL and 90-day mortality in patients with intracerebral hemorrhage. Stroke 2009; 40:1917.2.Rodriguez-Luna D, Rubiera M, Ribo M, et al. Serum low-density lipoprotein cholesterol level predicts hematoma growth and clinical outcome after acute intracerebral hemorrhage. Stroke 2011; 42:2447. 25. OTHER FACTORS: CHOLESTEROL /STATIN One case-control study found that statin use prior to ICH was associated with reduced mortality (OR 0.47) and increased probability of a favorable outcome (OR = 2.08) with similar results found in a meta-analysis of published studies of ICH and statin use (n:936 vs 2284) [1]. 1.Biffi A, Devan WJ, Anderson CD, et al. Statin use and outcome after intracerebral hemorrhage: case-control study and metaanalysis. Neurology 2011; 76:1581. 26. RECOMMENDATION: CHOLESTEROL /STATIN Given the conflicting data, it seems to be reasonable to weigh the benefits and possible risks of statin therapy in individual patients who are at risk for ICH recurrence.(1,2,3) 1.Westover MB, Bianchi MT, Eckman MH, Greenberg SM. Statin use following intracerebral hemorrhage: a decision analysis. Arch Neurol 2011; 68:573.2.Goldstein LB. Statins after intracerebral hemorrhage: to treat or not to treat. Arch Neurol 2011; 68:565.3.Amarenco P, Labreuche J. Lipid management in the prevention of stroke: review and updated meta-analysis of statins for stroke prevention. Lancet Neurol 2009; 8:453. 27. OTHER FACTORS: FEVER A meta-analysis analyzed fever and outcome in patients with neurologic injury, including hemorrhagic and/or ischemic stroke [1]. Fever was significantly associated with increased mortality rates, greater disability, more dependence, worse functional outcome, greater severity, and longer intensive care unit and hospital stays. 1.Greer DM, Funk SE, Reaven NL, et al. Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke 2008; 39:3029. 28. FEVER The PAIS trial evaluated 1400 adults no later than 12 hours after symptom onset of acute ischemic stroke and intracerebral hemorrhage [1]. Included patients had a body temperature of 36C to 39C. Compared with placebo, paracetamol (acetaminophen) 1 g six times daily for three days did not improve outcome [1].In a systematic review and meta-analysis of five small randomized controlled trials with a total of 293 patients, there was no benefit for pharmacologic temperature reduction for acute stroke [2]. All the trials enrolled patients within 24 hours of stroke onset, and the duration of treatment ranged from 24 hours to five days. With addition of results from the PAIS trial, the update