5. Epidemiologic features
Incidence
10~20 cases per 100,000
Increases with age
Men, especially older than 55 years old
Blacks and Japanese
Hypertension  the most important !

6. Cerebral Hemorrhage Up to 50%, 30 day mortality
Little effective therapy

7. ICH – Worse Outcomes Than Ischemic Stroke
100%
Independent
90%
Dependent
80%
70%
60%
50%
40%
Dead
30%
ICH accounts for 10% to 15% of all strokes and is associated with the highest mortality and morbidity.1 The worldwide incidence of ICH ranges from 10 to 20 cases per 100,000 population.2 Between 35% and 52% of patients with ICH die within 1 month of symptom onset,3-5 and only 20% are functionally independent at 6 months.5
American Heart Association. Heart Disease and Stroke Statistics–2005 Update.
Qureshi AI et al. N Engl J Med. 2001;344:
Broderick JP et al. J Neurosurg. 1993;78:
Anderson CS et al. J Neurol Neurosurg Psychiatry. 1994;57:
Counsell C et al. Cerebrovasc Dis. 1995;5:26-34.
20%
10% 0%
ICH
Ischemic
1. American Heart Association. Heart Disease and Stroke Statistics-2005 Update; Qureshi AI. et al. N Engl J Med. 2001;344: ; 3. Broderick JP. et al. Stroke. 1999;30: ; 4. Broderick JP. et al. N Engl J Med. 1992;326:

8. These structures include the Thalamus
Deep intracerebral hemorrhage is a type of stroke due to bleeding within the deep structures of the brain.
These structures include the Thalamus
Basal ganglia
Pons
Cerebellum.

9. Sites of Intracerebral Hemorrhage
Quereshi et al. N Engl J Med. 2001;344:

10. Hypertensive Intracerebral Hem: Sites
55% 15 10
1. Putamen-Claustrum
2. Cerebral white matter
3. Thalamus
4. Pons
5. Cerebellum

11. Stroke Evolution
Both ischemic stroke and hemorrhagic stroke are dynamic, evolving conditions
Shown on serial imaging studies with CT, MRI and PET
This changing pathophysiology results in increased lesion volume and worse outcome
Therapies aimed at limiting stroke growth

12. Hematoma Growth Hematomas expand on serial CT 38% <24 hours
Continued bleeding or rebleeding
Adverse prognosis
Silva et al. Stroke. 2005

13. Adverse Prognostic Factors
Old age
Large hematoma volume
Hematoma growth & increase with time
Low GCS
Intraventricular bleeding or extension
Infratentorial site

14. Hemorrhage and Volume
Expect good recovery for small volume less than 10 ml
Mortality 90% for comatose patients with large volume more than 60 ml

15. Hematoma Growth
3 hours

16. 9 hours

17. 6.5 hours after onset
2.0 hours after onset

18. Symptoms Change level of consciousness Apathetic Lethargy
Sleepiness Stupor
Coma & Unconsciousness *

19. Headache
Nausea or vomiting
Hemiplegia or hemiparesis
Hemihypesthesia

20. Diagnosis CT scan infarction or hemorrhage
Location and size of the hematoma
Presence of ventricular extension
Hydrocephalus

21. Diagnosis
Conventional angiography for secondary cause of ICH ( AVM, aneurysm..)
MRI, MRA  sensitivity ?

22. Diagnosis Complete blood count (CBC) & Platelet count Bleeding time
Blood clotting tests (Prothrombin time or partial thromboplastin time)
Liver function tests & Kidney function tests

23. Medical Management of Acute ICH

24. Management Evaluation & management Hyperventilation, Oxygen
Head elevation 30 degree

25. ICH: Cerebral Edema Osmolar therapy
High-dose 20% mannitol (1.4 g/kg) results in better ICP control and outcome than lower doses
GUIDELINE: Mannitol 20% for patients with increased ICP or symptomatic mass effect
Yu YL. et al. Stroke. 1992; 23:967
Cruz J. et al. Neurosurgery. 2002; 51:628

26. Management Mass effect & intracranial hypertension
Hematoma, edema tissue, obstructive hydrocephalus herniation !
Use of hyperventilation
and osmotic agent improved the long-term outcome

27. Management Intensive monitoring of neurologic & cardiovascular status
Instability is highest during the first 24 hrs
GCS, hourly BP

28. ICH: Cerebral Edema Dexamethasone
No benefit on outcome, but complications (infections and hyperglycemia) are more common
STANDARD: No Steroids!
Poungvarin N. et al. N Engl J Med. 1987;316:1229
Tellz H. et al. Stroke. 1973;4(4):541-6

29. ICH: Blood Pressure Management
Management of blood pressure
Elevation of blood pressure  expansion of hematoma poor outcome !

30. May ameliorate local edema May limit early hematoma growth
BP Reduction
Potential benefits:
May ameliorate local edema
May limit early hematoma growth
Potential risk:
Aggravation of perilesional ischemia
OPTION: Maintain MAP <130 mm Hg
Aggressive option: MAP ≤105 mm Hg
Broderick et al. Stroke. 1999;30:905

31. ICH: Blood Pressure Management
BP Reduction: preferred IV agents
Labetolol or esmolol (b blockers)
Nicardipine (CCB)
Fenoldopam (dopamine agonist)
Best to avoid
Nitroprusside
Rose J. and Mayer SA. Neurocritical Care. 2004;1:287

32. ICH: Seizure Prophylaxis
Seizure after ICH
10% have generalized tonic-clonic seizures
OPTION: Prophylactic phenytoin for 7 days for patients with large (especially lobar) ICH at risk for increased ICP
Passero S. et al. Epilepsia. 2002;43:1175

33. Seizures and recurrent hemorrhage
Most seizure  within 24 hrs
Anticonvulsants  discontinued after the first month if no seizure.
Seizures more than 2 weeks  at risk of further seizure  long-term treatment.

34. Surgical Management of ICH

35. Ventricular Drainage
Hydrocephalus is an independent predictor of poor outcome
External drainage is associated with a 25% improved survival rate
U. Of Michigan Stroke Program

36. Cerebellar Hematoma Can be approached with minor damage
Decompression of brain stem
Surgical  GCS less than 14, volume > 40 ml

37. Surgery
U. Of Michigan Stroke Program

38. Goals of Surgery for ICH
Prevent herniation
Improve functional outcome
U. Of Michigan Stroke Program

39. Prognosis The outlook depends on the size of the hematoma
and the amount of brain swelling.
Recovery may occur completely,
or there may be some permanent loss of brain function.
Death is possible, and may quickly occur despite prompt medical treatment.
Medications, surgery, or other treatments may have severe side effects.

40. Complications Hydrocephalus Fluid build-up in the brai
Loss of cognitive function & Vision loss
Permanent neurological deficit
Surgery complications

41. Subarachnoid Hemorrhage (SAH)

45. Causes of SAH Rupture of an existing aneurysm 85% anteriorly
Especially the anterior communicating artery
Aneurismal size often >7mm and
Rupture of an AV malformation
Trauma
Tumor

50. Physical examination Third-nerve palsy: P-com
Sixth-nerve palsy: post. Fossa
Bilateral weakness in legs or abulia: A-com
Nystagmus or ataxia: post. Fossa
Aphasia, hemiparesis: MCA

51. subhyaloid hemorrhages

54. Lumbar puncture Hx,PE:(+), CT(-) Xanthochromia: hemoglobin-->
oxyhemoglobin (reddish pink)
bilirubin (yellow): 12 hr
centrifuged--> spectrophotometry
Sensitivity: (12hr~2wk)

55. Angiography
Gold standard
Sources: 80-85%

56. Initial Management Monitor closely for signs of raised ICP
Intubated (if not already)
Hyperventilated
Mannitol
Surgery (clips/coils/drains)

62. Neurologic complication
Rebleeding
Hydrocephalus
Vasospasm/ Ischemia
Seizures
Cerebral edema