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Intracerebral Hemorrhage. Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL Marc Dorfman, MD, FACEP,

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Presentation on theme: "Intracerebral Hemorrhage. Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL Marc Dorfman, MD, FACEP,"— Presentation transcript:

1 Intracerebral Hemorrhage

2 Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL Marc Dorfman, MD, FACEP, MACP EM Residency Program Director Resurrection Medical Center Chicago, IL Marc Dorfman, MD, FACEP, MACP

3 Case 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

4 Marc Dorfman, MD, FACEP, MACP Physical 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

5 Marc Dorfman, MD, FACEP, MACP More History Long standing HypertensionLong standing Hypertension Unclear how well it was controlledUnclear how well it was controlled Postive-Tobbaco/AlcoholPostive-Tobbaco/Alcohol

6 Marc Dorfman, MD, FACEP, MACP Neurological Exam Neurological exam:Neurological exam: no gag reflex, withdraws to pain, +4 DTRno gag reflex, withdraws to pain, +4 DTR

7 Marc Dorfman, MD, FACEP, MACP GCS Eyes-0Eyes-0 Verbal-0Verbal-0 Motor-4Motor-4

8 NIH Stroke Scale

9 Marc Dorfman, MD, FACEP, MACP NIHSS Score Stroke scale 38Stroke scale 38

10 Marc Dorfman, MD, FACEP, MACP

11 Key Clinical Questions What is the epidemiology of ICH?What is the epidemiology of ICH? What are the most common etiologies ICH?What are the most common etiologies 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 than Ischemic stroke patients?Do patients with ICH present different than Ischemic stroke patients? Does hemorrhage volume and GCS predict outcome?Does hemorrhage volume and GCS predict outcome?

12 Marc Dorfman, MD, FACEP, MACP Key Clinical Questions How does hemorrhage volume increase over time?How does hemorrhage volume increase over time? What is the expected outcome of a patient with ICH?What is the expected outcome of a patient with ICH?

13 Marc Dorfman, MD, FACEP, MACP Mission Statement ICH is a cause of significant mortality and morbidity. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical and medical managements of patients with ICH. No consistently efficacious strategies have been identified in such investigations. Management of ICH unfortunately remains heterogeneous across institutions, and continues to suffer from the lack of proven medical and surgical effectiveness.ICH is a cause of significant mortality and morbidity. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical and medical managements of patients with ICH. No consistently efficacious strategies have been identified in such investigations. Management of ICH unfortunately remains heterogeneous across institutions, and continues to suffer from the lack of proven medical and surgical effectiveness. THIS IS CHANGINGTHIS IS CHANGING Update on management of intracerebral hemorrhage; Neurosurgery Focus 15;

14 Marc Dorfman, MD, FACEP, MACP Algorithm Qureshi A, Tuhrim S: Spontaneous Intracerebral Hemorrhage; NEJM, Vol 344, No 19 May 10, 2001;

15 Marc Dorfman, MD, FACEP, MACP Intracranial Hemorrhage EpidemiologyEpidemiology EtiologyEtiology PathophysiologyPathophysiology

16 Marc Dorfman, MD, FACEP, MACP Stroke 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 Stroke 15-20% Ischemic Stroke 80-85% Intracerebral Hemorrhage 2/3 Subarachnoid Hemorrhage 1/3

17 Marc Dorfman, MD, FACEP, MACP ICH-Epidemiology 10-15% of all strokes (80% ischemic)10-15% of all strokes (80% 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 Americans, Japanese, and Hispanic populationsIncreased incidence in African Americans, Japanese, and Hispanic populations Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005

18 Marc Dorfman, MD, FACEP, MACP ICH 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 independent at 6 monthsOne-fifth of survivors are independent at 6 months 7000 operations annually in USA to remove blood7000 operations annually in USA to remove blood Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 199;30:

19 Marc Dorfman, MD, FACEP, MACP ICH Epidemiology-30 Day Mortality 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

20 Marc Dorfman, MD, FACEP, MACP Etiology Primary ICH (78-88% cases)- spontaneous rupture of small vessels damaged byPrimary ICH (78-88% cases)- spontaneous rupture of small vessels damaged by Hypertension (basal ganglia, thalamus, pons, cerebellum)Hypertension (basal ganglia, thalamus, pons, cerebellum) Cerebral Amyloid AngiopathyCerebral Amyloid Angiopathy

21 Marc Dorfman, MD, FACEP, MACP Etiology Pre-morbid Hypertension increases risk by 3.9%Pre-morbid Hypertension increases risk by 3.9% Improved control of hypertension appears to reduce the incidence if intracerebral hemorrhageImproved control of hypertension appears to reduce the incidence if intracerebral hemorrhage

22 Marc Dorfman, MD, FACEP, MACP Hypertensive ICH HypertensionHypertension EssentialEssential EclampsiaEclampsia SympathomimeticsSympathomimetics CocaineCocaine AmphetaminesAmphetamines PhenylpropanolaminePhenylpropanolamine

23 Marc Dorfman, MD, FACEP, MACP Etiology Cerebral Amyloid Angiopathy- 50% individuals greater than 80 years oldCerebral Amyloid Angiopathy- 50% individuals greater than 80 years old

24 Marc Dorfman, MD, FACEP, MACP Etiology Low serum cholesterol (<160 reason unknown)Low serum cholesterol (<160 reason unknown) Alcohol consumptionAlcohol consumption Previous ICH-especially lobar hemorrhagePrevious ICH-especially lobar hemorrhage

25 Marc Dorfman, MD, FACEP, MACP ICH Etiologies TraumaTrauma Vascular malformationVascular malformation AneurysmAneurysm AvmAvm Cavernous hemangiomasCavernous hemangiomas TumorTumor CoagulopathyCoagulopathy VasculitisVasculitis

26 Marc Dorfman, MD, FACEP, MACP Pathophysiology Primary-immediate effectsPrimary-immediate effects Hemorrhage growthHemorrhage growth Increased ICPIncreased ICP Secondary effectsSecondary effects Downstream effectsDownstream effects EdemaEdema IschemiaIschemia Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005

27 Marc Dorfman, MD, FACEP, MACP ICH Hemorrhage Growth Several studies describe patients who had an increase in the volume of parenchymal hemorrhage on repeat CT scansSeveral studies describe patients who had an increase in the volume of parenchymal hemorrhage on repeat CT scans

28 Marc Dorfman, MD, FACEP, MACP ICH Hemorrhage Volume Old concept-Hemorrhage static process; bleeding complete in a minutesOld concept-Hemorrhage static process; bleeding complete in a minutes New concept-Hemorrhage is dynamic; process continues for several hoursNew concept-Hemorrhage is dynamic; process continues for several hours

29 Marc Dorfman, MD, FACEP, MACP ICH Volume Growth

30 Marc Dorfman, MD, FACEP, MACP ICH 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 volume of parenchymal hemorrhage38% patients with > 33% growth in volume of parenchymal hemorrhage

31 Marc Dorfman, MD, FACEP, MACP ICH Volume Growth Comparison of variables between Baseline and 1 hour CTs

32 Marc Dorfman, MD, FACEP, MACP ICH Growth Study Conclusion Substantial early hemorrhage growth in patients with with intracerebral hemorrhage is common and is associated with neurological deterioration.Substantial early hemorrhage growth in patients with with intracerebral hemorrhage is common and is associated with neurological deterioration. Randomized treatment trials are needed to determine whether this ongoing bleeding and frequent neurological deterioration can be improvedRandomized treatment trials are needed to determine whether this ongoing bleeding and frequent neurological deterioration can be improved

33 Marc Dorfman, MD, FACEP, MACP ICH Hemorrhage Growth Hematoma growth occurs in patients with normal coagulation profilesHematoma growth occurs in patients with normal coagulation profiles Hematoma enlargement is associated with a worse outcomeHematoma enlargement is associated with a worse outcome Hematoma growth occurs within the first few hours (up to 40% in the first 3 hours) and is rare after 24 hoursHematoma growth occurs within the first few hours (up to 40% in the first 3 hours) and is rare after 24 hours Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005

34 Marc Dorfman, MD, FACEP, MACP Hemorrhage Growth-Predictors Initial Hematoma volumeInitial Hematoma volume Early PresentationEarly Presentation Irregular shapeIrregular shape Liver diseaseLiver disease HypertensionHypertension HyperglycemiaHyperglycemia Alcohol useAlcohol use HypofibrinogenimaHypofibrinogenima Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005

35 Marc Dorfman, MD, FACEP, MACP Hemorrhage Volume-Mortality Volume graters 60 cm3Volume graters 60 cm3 Deep-93%Deep-93% Lobar-71%Lobar-71% Volumes cm 3Volumes 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

36 Marc Dorfman, MD, FACEP, MACP Hemorrhage 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 with hemorrhage multiplied by slick thickness in cmC-approximate number of CT slices with hemorrhage multiplied by slick thickness in cm L Schwamm; Guidelines for Emergency Department Management of Brain Hemorrhage 2, 2004

37 Marc Dorfman, MD, FACEP, MACP Secondary Effects of ICH Hematoma initiates edemaHematoma initiates edema Edema is from osmotically active proteins from the clotEdema is from osmotically active proteins from the clot Vasogenic and cytotoxic edema lead to disruption of blood brain barrier and death to neuronsVasogenic and cytotoxic edema lead to disruption of blood brain barrier and death to neurons There may be unidentified secondary mediators of both neuronal injury and edema ( nuclear factor kappa-beta)There may be unidentified secondary mediators of both neuronal injury and edema ( nuclear factor kappa-beta) Qureshi A, Tuhrim S: Spontaneous Intracerebral Hemorrhage; NEJM, Vol 344, No 19 May 10, 2001;

38 Marc Dorfman, MD, FACEP, MACP ICH-Presentation Basal ganglia (50%)Basal ganglia (50%) Contralateral hemiparesis, sensory loss, conjugate gazeContralateral hemiparesis, sensory loss, conjugate gaze Lobar regions (20-50%)Lobar regions (20-50%) Contralateral hemiparesis or sensory loss, aphasia, neglect, or confusionContralateral hemiparesis or sensory loss, aphasia, neglect, or confusion Thalamus (10-15%)Thalamus (10-15%) Contralateral hemiparesis, sensory loss, gaze paresisContralateral hemiparesis, sensory loss, gaze paresis Pons (5-12%)Pons (5-12%) Quadriparesis, facial weakness, decreased level consciousnessQuadriparesis, facial weakness, decreased level consciousness Cerebellum (1-5%)Cerebellum (1-5%) Ataxia, miosis, vertigo, gaze paresisAtaxia, miosis, vertigo, gaze paresis Acute Evaluation and Management of Intracerebral Hemorrhage; Stroke 1996

39 Marc Dorfman, MD, FACEP, MACP ICH 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%)

40 Marc Dorfman, MD, FACEP, MACP ICH-Hypertension Risk factor for bleedingRisk factor for bleeding May promote rebleeding (logical but unproven)May promote rebleeding (logical but unproven) The big question-Will treating hypertension promote ischemia or how low can we go?The big question-Will treating hypertension promote ischemia or how low can we go?

41 Marc Dorfman, MD, FACEP, MACP Altered Mental Status Early decrease in level of consciousness seen about 50% patientsEarly decrease in level of consciousness seen about 50% patients Uncommon finding in patients with ischemic strokeUncommon finding in patients with ischemic stroke Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30:

42 Marc Dorfman, MD, FACEP, MACP Headache Occurs about 40% of patientsOccurs about 40% of patients 17% with ischemic stroke17% with ischemic stroke Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30:

43 Marc Dorfman, MD, FACEP, MACP Vomiting 49% ICH49% ICH 2% Ischemic stroke2% Ischemic stroke 45% with SAH45% with SAH Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30:

44 Marc Dorfman, MD, FACEP, MACP ICHCVA Decrease LOC 50%Uncommon Headache40%17% Vomiting49%2%

45 Marc Dorfman, MD, FACEP, MACP Seizure 28% of patients first 72 hours28% of patients first 72 hours Mostly lobarMostly lobar Associated with Neurological worseningAssociated with Neurological worsening Trend toward worse outcomeTrend toward worse outcome Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005

46 Marc Dorfman, MD, FACEP, MACP Presentation Sudden onset of focal neurological deficitSudden onset of focal neurological deficit Progresses over minutes to hoursProgresses over minutes to hours Headache, N/V, Decreased LOC, Elevated BPHeadache, N/V, Decreased LOC, Elevated BP Broderick: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage ;Stroke 1999;30:

47 ICH Diagnosis CT scanCT scan CT scan is the most effective tool in the ED CT scan is excellent for imaging blood

48 Marc Dorfman, MD, FACEP, MACP Poor Outcome Risk Factors Large or increasing volume of hematomaLarge or increasing volume of hematoma Low GCS on admissionLow GCS on admission Interventricular clot extension and/or hydrocehalusInterventricular clot extension and/or hydrocehalus Anticoagulation agentsAnticoagulation agents Relative edemaRelative edema Update on management of intracerebral hemorrhage; Neurosurgery Focus 15;

49 Marc Dorfman, MD, FACEP, MACP Poor Outcomes- Intraventricular Extension Hydrocephalus Independent prognostic indicatorIndependent prognostic indicator Important cause of neurological deteriorationImportant cause of neurological deterioration Location importance?Location importance? Ventriculostomy-helpful?Ventriculostomy-helpful? Priorities for Clinical Research in ICH:NINDS ICH Workshop; Stroke March 2005

50 Marc Dorfman, MD, FACEP, MACP Outcome predictor Initial GCSInitial GCS Initial hematoma volumeInitial hematoma volume If GCS 60 ml mortality at one month 90%If GCS 60 ml mortality at one month 90% GCS > 9 and hematoma volume 17%GCS > 9 and hematoma volume 17% Broderick, Brott; Volume if intracerebral hemorrhage: a powerful and easy-to-use predictor of 30 day mortality. Stroke 1993;24:987-93

51 Marc Dorfman, MD, FACEP, MACP ICH 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(1) <30(0) IVH (yes, no)IVH (yes, no) Infratentorial origin of ICH (yes,no)Infratentorial origin of ICH (yes,no) Age 80 yrs(1)Age 80 yrs(1) Hemphill III, Bonovich: The ICH Score;Stroke,April

52 Marc Dorfman, MD, FACEP, MACP ICH Score If score was six or greater all patients diedIf score was six or greater all patients died If score was zero all patients livedIf score was zero all patients lived Hemphill III, Bonovich: The ICH Score;Stroke,April

53 Marc Dorfman, MD, FACEP, MACP ED 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 of arrivalPatient expired within two hours of arrival

54 Marc Dorfman, MD, FACEP, MACP Key Learning Points ICH makes up only 10-15% strokesICH makes up only 10-15% strokes ICH occurs in hypertensives greater then 55 yrs of ageICH occurs in hypertensives greater then 55 yrs of age ICH presents differently than ischemic strokeICH presents differently than ischemic stroke ICH volume expands over time-this is a marker for poor outcomeICH volume expands over time-this is a marker for poor outcome One can risk stratify poor outcomes based on simple numbers such as GCS, hemorrhage volumeOne can risk stratify poor outcomes based on simple numbers such as GCS, hemorrhage volume

55 Questions?? Marc Dorfman, MD Questions?? Marc Dorfman, MD dorfman_ich_aaem_2005 2/12/2005 7:48 PM Marc Dorfman, MD, FACEP, MACP


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