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

1 Intracranial 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 57 year old female57 year old female Sudden onset, severe headacheSudden onset, severe headache Took ASA for reliefTook ASA for relief Slurred speechSlurred speech CollapsedCollapsed

4 Marc Dorfman, MD, FACEP, MACP Physical Exam T 99.4 P52 BP 195/99 RR13T 99.4 P52 BP 195/99 RR13 Pupils-2 mm reactivePupils-2 mm reactive Neck-no JVD, bruitsNeck-no JVD, bruits CV-bradycardia, no murmurCV-bradycardia, no murmur Abd-bs+, soft, nt/ndAbd-bs+, soft, nt/nd Skin-warm and drySkin-warm and dry

5 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

6 Marc Dorfman, MD, FACEP, MACP GCS Eyes-1Eyes-1 Verbal-1Verbal-1 Motor-4Motor-4

7 NIH Stroke Scale

8 Marc Dorfman, MD, FACEP, MACP NIHSS Score Stroke scale 25Stroke scale 25

9 CT Scan

10 NY Times

11 Marc Dorfman, MD, FACEP, MACP Key Clinical Questions What are the most common etiologies and locations of ICH?What are the most common etiologies and locations of ICH? What are the goals of BP management?What are the goals of BP management? What are the optimal strategies for managing ICP?What are the optimal strategies for managing ICP? What other treatment modalities are available to the ED physcian?What other treatment modalities are available to the ED physcian?

12 Marc Dorfman, MD, FACEP, MACP Key Clinical Questions Which ICH patient require surgery?Which ICH patient require surgery? How does hemorrhage volume change over time?How does hemorrhage volume change over time? Does hemorrhage volume growth affect mortality?Does hemorrhage volume growth affect mortality? What are the new therapies being tested for this disease process?What are the new therapies being tested for this disease process?

13 Marc Dorfman, MD, FACEP, MACP Intracranial Hemorrhage EpidemiologyEpidemiology EtiologyEtiology DiagnosisDiagnosis TreatmentTreatment BP managementBP management Neurosurgical indicationsNeurosurgical indications New treatment modalitiesNew treatment modalities

14 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 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

15 Marc Dorfman, MD, FACEP, MACP ICH Types EpiduralEpidural SubduralSubdural SubarachnoidSubarachnoid IntraparencymalIntraparencymal IntraventricularIntraventricular CerebellarCerebellar

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

17 Marc Dorfman, MD, FACEP, MACP Hypertensive ICH 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, gaze paresisAtaxia, miosis, gaze paresis

18 Marc Dorfman, MD, FACEP, MACP Other ICH Etiologies AmyloidAmyloid TraumaTrauma Vascular malformation-Avm, cavernoushemangiomasVascular malformation-Avm, cavernoushemangiomas AneurysmAneurysm TumorTumor CoagulopathyCoagulopathy VasculitisVasculitis

19 Marc Dorfman, MD, FACEP, MACP ICH Presentation Hypertension (90%)Hypertension (90%) Altered mental status (50%)Altered mental status (50%) Headache (40%)Headache (40%) Seizures (6-7%)Seizures (6-7%)

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

21 Marc Dorfman, MD, FACEP, MACP ICH Rx Key Concepts Two key concepts:Two key concepts: Intracranial pressureIntracranial pressure Elevated when ICP >20 mm HgElevated when ICP >20 mm Hg Cerebral perfusion pressureCerebral perfusion pressure CPP=MAP-ICPCPP=MAP-ICP Must maintain ICP > 70 mm HgMust maintain ICP > 70 mm Hg Example: MAP = 100, ICP = 20Example: MAP = 100, ICP = 20 CPP in above example = 80 mmHgCPP in above example = 80 mmHg

22 Marc Dorfman, MD, FACEP, MACP Increased ICP Treatment Intracranial Pressure (ICP): considered a major contributor to mortality when elevatedIntracranial Pressure (ICP): considered a major contributor to mortality when elevated Controlling ICP is considered essentialControlling ICP is considered essential OsmotherapyOsmotherapy HyperventilationHyperventilation Barbiturate comaBarbiturate coma

23 Marc Dorfman, MD, FACEP, MACP Clinical Case: ED Rx Patient starts to vomitPatient starts to vomit B/P 266/122B/P 266/122 RSIRSI Lidocaine 100 mgsLidocaine 100 mgs Etomadate 20 mgsEtomadate 20 mgs SuccinylCholine 100 mgsSuccinylCholine 100 mgs Mannitol 150 ccsMannitol 150 ccs Elevate Head of BedElevate Head of Bed Hyperventilation to pCO25-30Hyperventilation to pCO25-30

24 Marc Dorfman, MD, FACEP, MACP Clinical Case: ED Rx Paralytics-Pancuronium 7 mgParalytics-Pancuronium 7 mg BP management-NiprideBP management-Nipride Steroids-Decadron 10 mgsSteroids-Decadron 10 mgs

25 Marc Dorfman, MD, FACEP, MACP Osmotherapy Osmotherapy-MannitolOsmotherapy-Mannitol Reduces cerebral edema by decreasing cerebral fluid volumeReduces cerebral edema by decreasing cerebral fluid volume Rebound effect-use less than 5 daysRebound effect-use less than 5 days 20% solution20% solution mg/kg maintain serum osmolarity mOsm/L mg/kg maintain serum osmolarity mOsm/L

26 Marc Dorfman, MD, FACEP, MACP HOB Elevation Elevate head of bed-decrease ICPElevate head of bed-decrease ICP Mechanical-helps drain blood by gravityMechanical-helps drain blood by gravity Does not allow blood to pool in cranium, which may occur if patient is left laying flatDoes not allow blood to pool in cranium, which may occur if patient is left laying flat

27 Marc Dorfman, MD, FACEP, MACP Endotracheal Intubation Intubation-not required, but airway protection and adequate ventilation are necessaryIntubation-not required, but airway protection and adequate ventilation are necessary Rely on clinical suspicion, not GCSRely on clinical suspicion, not GCS Hyperventilation decreases ICPHyperventilation decreases ICP pCO2 should be kept around 30-35pCO2 should be kept around Beneficial effect of sustained hyperventilation is not provenBeneficial effect of sustained hyperventilation is not proven

28 Marc Dorfman, MD, FACEP, MACP Paralytics Recommended in order to prevent increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT, all of which may cause ICP spikesRecommended in order to prevent increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT, all of which may cause ICP spikes ICP spikes associated with poorer outcome, especially in setting of elevated ICPICP spikes associated with poorer outcome, especially in setting of elevated ICP

29 Marc Dorfman, MD, FACEP, MACP ICP Monitors AHA recommends ICP monitors in patients with a GCS less than 9 and all patients whose condition is thought to be deteriorating due to elevated ICPAHA recommends ICP monitors in patients with a GCS less than 9 and all patients whose condition is thought to be deteriorating due to elevated ICP

30 Marc Dorfman, MD, FACEP, MACP BP Management Lower blood pressure to decrease risk of ongoing bleeding from ruptured small arteriesLower blood pressure to decrease risk of ongoing bleeding from ruptured small arteries Overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injuryOveraggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injury Especially true with elevated ICPEspecially true with elevated ICP

31 Marc Dorfman, MD, FACEP, MACP BP Management AHA recommends blood pressure be maintained below a mean arterial pressure of 130 mm Hg in persons with a history of hypertensionAHA recommends blood pressure be maintained below a mean arterial pressure of 130 mm Hg in persons with a history of hypertension If there is an ICP monitor:If there is an ICP monitor: ICP should be kept < 20 m HgICP should be kept < 20 m Hg Cerbral perfusion pressure (MAP- ICP) should be kept > 70 mm HgCerbral perfusion pressure (MAP- ICP) should be kept > 70 mm Hg

32 Marc Dorfman, MD, FACEP, MACP BP Management Avoid hypotensionAvoid hypotension If systolic BP drops to less than 90 mmHg, consider judicious fluid boluses and/or start pressorsIf systolic BP drops to less than 90 mmHg, consider judicious fluid boluses and/or start pressors

33 Marc Dorfman, MD, FACEP, MACP BP Management LabetalolLabetalol 20 mg IV, followed by mg IV q10 min20 mg IV, followed by mg IV q10 min Titrate to BP or max 300 mgs adminTitrate to BP or max 300 mgs admin NiprideNipride mics/kg/min mics/kg/min Theoretically can increase cerebral blood flow and thereby intracranial pressureTheoretically can increase cerebral blood flow and thereby intracranial pressure

34 Marc Dorfman, MD, FACEP, MACP BP Management Treatment should be started within 6 hours of symptom onsetTreatment should be started within 6 hours of symptom onset A Prospective Multicenter Study to Evaluate the Feasibility and Safety of Aggressive Antihypertensive Treatment in Patients with Acute Intracerebral HemorrhageA Prospective Multicenter Study to Evaluate the Feasibility and Safety of Aggressive Antihypertensive Treatment in Patients with Acute Intracerebral Hemorrhage Journal of Intensive Care Medicine, Vol 20, No 1Journal of Intensive Care Medicine, Vol 20, No 1 Burke, Dorfman-not yet publishedBurke, Dorfman-not yet published

35 Marc Dorfman, MD, FACEP, MACP Fever Management Elevated temperatures can increase the degree of ischemic injury.Elevated temperatures can increase the degree of ischemic injury. Etiologies include infection, neuronal injury, SIRSEtiologies include infection, neuronal injury, SIRS Studies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation.Studies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation. Treat temperture > 38.5˚ CTreat temperture > 38.5˚ C Acetaminophen or a cooling blanket best options.Acetaminophen or a cooling blanket best options.

36 Marc Dorfman, MD, FACEP, MACP Seizure Therapy Neuronal injury may lead to seizuresNeuronal injury may lead to seizures Nonconvulsive seizures may contribute to coma in up to 10% of neurocritical patientsNonconvulsive seizures may contribute to coma in up to 10% of neurocritical patients Consider prophylactic antiepileptic therapy in setting of ICHConsider prophylactic antiepileptic therapy in setting of ICH Lobar hemorrhage-35% seizure rateLobar hemorrhage-35% seizure rate Fosphenytoin or phenytoinFosphenytoin or phenytoin

37 Marc Dorfman, MD, FACEP, MACP Medical Therapy EuvolemiaEuvolemia Isotonic crystalloid solutionsIsotonic crystalloid solutions Electrolyte abnormalitiesElectrolyte abnormalities Correct deficitsCorrect deficits Acid/base disordersAcid/base disorders Correct them if presentCorrect them if present Steroids-no benefitSteroids-no benefit

38 Marc Dorfman, MD, FACEP, MACP Blood Clot

39 Marc Dorfman, MD, FACEP, MACP ICH Hemorrhage Growth Until recently, bleeding in patients with ICH was thought to be completed within minutes of onsetUntil recently, bleeding in patients with ICH was thought to be completed within minutes of onset Several small studies describe a few patients who had an increase in the volume of parenchymal hemorrhage on repeated CT scansSeveral small studies describe a few patients who had an increase in the volume of parenchymal hemorrhage on repeated CT scans

40 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

41 Marc Dorfman, MD, FACEP, MACP ICH Hemorrhage Growth Early Hemorrhage Growth in Patients With Intracerbral HemorrhageEarly Hemorrhage Growth in Patients With Intracerbral Hemorrhage Brott, Broderick, KothariBrott, Broderick, Kothari Stroke Vol 28, 1 January 1998Stroke Vol 28, 1 January 1998

42 Marc Dorfman, MD, FACEP, MACP ICH Growth: Study Purpose Prospectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to neurological deteriorationProspectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to neurological deterioration

43 Marc Dorfman, MD, FACEP, MACP ICH Growth Study Design 102 patients102 patients CT scan 3 hours and 24 hoursCT scan 3 hours and 24 hours 38% patients with > 33% growth in volume of parenchymal hemorrhage38% patients with > 33% growth in volume of parenchymal hemorrhage

44 Marc Dorfman, MD, FACEP, MACP ICH Growth: Conclusions 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

45 Marc Dorfman, MD, FACEP, MACP ICH Factor VIIa Study Safety and Feasibility of Recombinant Factor VIIa for Acute Intracerebral HemorrhageSafety and Feasibility of Recombinant Factor VIIa for Acute Intracerebral Hemorrhage Mayer, Nikolai, BrunMayer, Nikolai, Brun Stroke, Jan 2005, 36(1) p74-9Stroke, Jan 2005, 36(1) p74-9

46 Marc Dorfman, MD, FACEP, MACP ICH Factor VIIa Study Purpose Factor VIIa-promotes clotting- know to do so in hemophiliacsFactor VIIa-promotes clotting- know to do so in hemophiliacs Activated factor VII promotes hemostasis at sites of vascualr injury and may minimize hematoma grwoth in ICHActivated factor VII promotes hemostasis at sites of vascualr injury and may minimize hematoma grwoth in ICH

47 Marc Dorfman, MD, FACEP, MACP ICH Factor VIIa Study Design 48 subjects48 subjects Randomized double blind placebo controlledRandomized double blind placebo controlled Escalating doses of factor VIIEscalating doses of factor VII Endpoint-frequency of adverse eventsEndpoint-frequency of adverse events

48 Marc Dorfman, MD, FACEP, MACP ICH Factor VIIa Study Conclusion Phase II trialPhase II trial No major safety concernsNo major safety concerns Larger study needed to determine if factor VII can safely and effectively limit ICH growthLarger study needed to determine if factor VII can safely and effectively limit ICH growth

49 Marc Dorfman, MD, FACEP, MACP ED Patient Management Neurosurgery consultedNeurosurgery consulted EVD placed in the EDEVD placed in the ED Patient taken to the OR for evacuation of hematomaPatient taken to the OR for evacuation of hematoma BP-119/79 P-92 RR-12BP-119/79 P-92 RR-12

50 Marc Dorfman, MD, FACEP, MACP Patient Outcome Next day: brain flow studiesNext day: brain flow studies Patient declared brain deadPatient declared brain dead Patient extubatedPatient extubated

51 Marc Dorfman, MD, FACEP, MACP ICH Surgical Indications Cerebellar hemorrhage > 3 cm who are deteriorating or with brain stem compression and hydrocephalus from ventricular obstructionCerebellar hemorrhage > 3 cm who are deteriorating or with brain stem compression and hydrocephalus from ventricular obstruction Vascular malformation if lesion is surgically accessible and patient has chance for good outcomeVascular malformation if lesion is surgically accessible and patient has chance for good outcome Young patients with a moderate or large lobar hemorrhage who are clinically deterioratingYoung patients with a moderate or large lobar hemorrhage who are clinically deteriorating

52 Marc Dorfman, MD, FACEP, MACP Non-Surgical ICH Pts Small Hemorrhages (10 cm 3 )Small Hemorrhages (10 cm 3 ) Minimal neurological deficitsMinimal neurological deficits GCS < 4 (excluding cerebellar hemorrhage with brain stem compression)GCS < 4 (excluding cerebellar hemorrhage with brain stem compression)

53 Marc Dorfman, MD, FACEP, MACP Key Learning Points ICH is a dynamic, not a static processICH is a dynamic, not a static process Hemorrhage volume can increase over timeHemorrhage volume can increase over time CT scan is the most important tool in your diagnostic toolboxCT scan is the most important tool in your diagnostic toolbox Manage blood pressure, noting that guidelines are variableManage blood pressure, noting that guidelines are variable Aggressively manage fever and seizuresAggressively manage fever and seizures Consider hyperventilation and paralytics in setting of increased ICP and deteriorationConsider hyperventilation and paralytics in setting of increased ICP and deterioration

54 Marc Dorfman, MD, FACEP, MACP Key Learning Points Most ICH patients are non-surgicalMost ICH patients are non-surgical Consult your neurosurgeon earlyConsult your neurosurgeon early Steroids-no benefitSteroids-no benefit There are promising new therapies such as Factor VII on the horizonThere are promising new therapies such as Factor VII on the horizon

55 Questions?? Marc Dorfman, MD Questions?? Marc Dorfman, MD ferne_aaem2005_dorfman_ich_cdformat.ppt 2/14/2005 7:02 PM Marc Dorfman, MD, FACEP, MACP


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