Edward C. Jauch, MD, MS FACEP 1 Research Horizons in the Acute Management of ICH

Edward C. Jauch, MD, MS FACEP 2 Edward C. Jauch, MD MS FACEP Assistant Professor Associate Director of Research Department of Emergency Medicine University of Cincinnati College of Medicine Faculty, Greater Cincinnati / Northern Kentucky Stroke Team

Current Recommendations for Management of Intracerebral Hemorrhage (Broderick, Stroke 1999) Emergency Medicine representationEmergency Medicine representation New guidelines due 2005New guidelines due 2005 Edward C. Jauch, MD MS FACEP

Edward C. Jauch, MD, MS FACEP 4 Medical Management ABC’s Blood pressure control ICP management –Hyperventilation –Osmotherapy –No role for glycerol, corticosteroids, hemodilution Other –Prevention of hyperthermia –Fluid management (CVP at 5-12 mm Hg) Modifications for age, comorbidities, size, severity, location Seizure control Find somebody to take the patient

The Future of ICH Treatment Edward C. Jauch, MD MS FACEP

Edward C. Jauch, MD, MS FACEP 6 Time Will Always Mean Brain! (Lancet 2004; 363: 768–74)

Edward C. Jauch, MD, MS FACEP 7 Priorities and Potential for ICH Treatment Prevention of primary and secondary injury: –Goal directed physiologic management Systemic Local –Minimize edema/hematoma growth and injury Anticoagulation reversal Maximize hemostasis Penumbral protection –Early hematoma evacuation / decompression

Blood Pressure Management (Broderick, Stroke 1999) Edward C. Jauch, MD MS FACEP

Edward C. Jauch, MD, MS FACEP 9 Blood Pressure Management No definitive data (yet) Hypertension very common –MAP > 140 in 34%, > 120 in 78% –Many return to baseline over first 24 hours Prospective RetrospectiveCase SeriesResults Meyer et al Lower BP good Dandapani et al Lower BP good Qureshi et al Lower BP bad Brott T et al 1995 Hematoma enlargement not associated with degree of HTN (Dr. Aninda Acharya, St.Louis University, Internet Stroke Center)

Edward C. Jauch, MD, MS FACEP 10 Blood Pressure Management Balancing act to minimize hematoma expansion while maximizing perihematomal ischemia Antihypertensive Treatment in Acute ICH –Stepwise intervention with nicardipine to lower SBP (R01NS044976) –Safety trial and secondary efficacy outcome

Edward C. Jauch, MD, MS FACEP 11 Penumbral Protection Neurotoxicity and the ischemic cascade occur very early Trials to blunt this response: –FAST-Mag (Phase III) Trial of magnesium in AIS and ICH –CHANT (NXY-059) (Phase II) –Localized hypothermia (animal studies)

Edward C. Jauch, MD, MS FACEP 12 Hematoma and Edema Management Treatment within four hours from onset 399 patients in 4 arms (40, 80, 160 μg/kg) Outcomes –Primary: 24 hour hematoma growth –Secondary: 90 day outcomes (Mayer, NEJM 2005;352: )

Edward C. Jauch, MD, MS FACEP 13 Factor rVIIa Treatment P=0.07P=0.05P=0.02

Edward C. Jauch, MD, MS FACEP 14 Factor rVIIa Treatment rFVIIa limits ICH growth, reduces mortality, and improves functional outcomes A small increase in the frequency of thromboembolic adverse events occurs with treatment (2% vs 7%, p=0.12) (Mayer, NEJM 2005;352: )

Edward C. Jauch, MD, MS FACEP 15 Surgical Approaches Decompressive surgery Hematoma removal / aspiration Intraventricular drainage and hematoma removal

Surgical Recommendations (Broderick, Stroke 1999) Edward C. Jauch, MD MS FACEP

Edward C. Jauch, MD, MS FACEP 17 Surgical Evacuation Largest surgical trial (1033 patients, 27 countries, 8 years) Surgery within 96 hours from onset vs medical management Outcome –PrimaryFavorable outcome at 6 months –SecondaryMortality (Mendelow, Lancet 2005;365: )

Edward C. Jauch, MD, MS FACEP 18 (Mendelow, Lancet 2005;365: ) Surgical Evacuation No difference in: –Favorable outcome (26% vs. 24%, OR 2.3) –Mortality (36% vs 37%, OR 1.2) –Mean total 6 month cost (£18452 vs £20513) Mortality curves

Edward C. Jauch, MD, MS FACEP 19 MISTIE Trial Stereotactic ICH evacuation with tPAStereotactic ICH evacuation with tPA –Multicenter phase II NIH study –Surgery in 24 hrs from onset –Stable clot for 6 hrs on serial CT –Similar dose-escalation tPA evacuation trials of IVH alone and IVH associated with ICH (DITCH Trial phase II)

Edward C. Jauch, MD, MS FACEP 20 Conclusions All forms of brain injury, from trauma to vascular events, will require rapid interventions Immediate global and local treatments will be the purview of the Emergency physician Time will always be brain

Questions?? Edward Jauch, MD, MS (513) Questions?? Edward Jauch, MD, MS (513) ferne_acep_2005_jauch_ich_reshorizon_cd 3/2/2005 4:21 PM Edward C. Jauch, MD, MS FACEP