Intracranial Intracranial Hemorrhage Hemorrhage
Jan 11, 2016
Intracranial HemorrhageIntracranial Hemorrhage
Marc Dorfman, MD, FACEP, MACPMarc Dorfman, MD, FACEP, MACP
EM Residency Program DirectorEM Residency Program Director
Resurrection Medical CenterResurrection Medical CenterChicago, ILChicago, IL
Marc Dorfman, MD, FACEP, MACP
Marc Dorfman, MD, FACEP, MACP
Case PresentationCase 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
Marc Dorfman, MD, FACEP, MACP
Physical ExamPhysical 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
Marc Dorfman, MD, FACEP, MACP
Neurological ExamNeurological Exam
• Neurological exam:Neurological exam:• no gag reflex, withdraws to no gag reflex, withdraws to
pain, +4 DTR pain, +4 DTR
Marc Dorfman, MD, FACEP, MACP
GCSGCS
• Eyes-1Eyes-1• Verbal-1Verbal-1• Motor-4Motor-4
NIH Stroke ScaleNIH Stroke Scale
NIH Stroke Scale
Marc Dorfman, MD, FACEP, MACP
NIHSS ScoreNIHSS Score
• Stroke scale 25Stroke scale 25
CT ScanCT Scan
NY TimesNY Times
Marc Dorfman, MD, FACEP, MACP
Key Clinical QuestionsKey Clinical Questions• What are the most common What are the most common
etiologies and locations of ICH?etiologies and locations of ICH?• What are the goals of BP What are the goals of BP
management?management?• What are the optimal strategies for What are the optimal strategies for
managing ICP?managing ICP?• What other treatment modalities are What other treatment modalities are
available to the ED physcian?available to the ED physcian?
Marc Dorfman, MD, FACEP, MACP
Key Clinical QuestionsKey Clinical Questions
• Which ICH patient require surgery?Which ICH patient require surgery?• How does hemorrhage volume How does hemorrhage volume
change over time? change over time? • Does hemorrhage volume growth Does hemorrhage volume growth
affect mortality?affect mortality?• What are the new therapies being What are the new therapies being
tested for this disease process?tested for this disease process?
Marc Dorfman, MD, FACEP, MACP
Intracranial HemorrhageIntracranial Hemorrhage• EpidemiologyEpidemiology• EtiologyEtiology• DiagnosisDiagnosis• TreatmentTreatment
• BP managementBP management• Neurosurgical indicationsNeurosurgical indications• New treatment modalitiesNew treatment modalities
Marc Dorfman, MD, FACEP, MACP
ICH EpidemiologyICH 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 One-fifth of survivors are independent at 6 monthsindependent at 6 months
• 7000 operations annually in 7000 operations annually in USA to remove blood USA to remove blood
Marc Dorfman, MD, FACEP, MACP
ICH TypesICH Types• EpiduralEpidural• SubduralSubdural• SubarachnoidSubarachnoid• IntraparencymalIntraparencymal• IntraventricularIntraventricular• CerebellarCerebellar
Marc Dorfman, MD, FACEP, MACP
Hypertensive ICHHypertensive ICH• HypertensionHypertension
• EssentialEssential• EclampsiaEclampsia• SympathomimeticsSympathomimetics
• CocaineCocaine• AmphetaminesAmphetamines• PhenylpropanolaminePhenylpropanolamine
Marc Dorfman, MD, FACEP, MACP
Hypertensive ICHHypertensive ICH• Basal ganglia (50%)Basal ganglia (50%)
• Contralateral hemiparesis, sensory loss, conjugate Contralateral hemiparesis, sensory loss, conjugate gazegaze
• Lobar regions (20-50%)Lobar regions (20-50%)• Contralateral hemiparesis or sensory loss, aphasia, Contralateral hemiparesis or sensory loss, aphasia,
neglect, or confusionneglect, or confusion• Thalamus (10-15%)Thalamus (10-15%)
• Contralateral hemiparesis, sensory loss, gaze Contralateral hemiparesis, sensory loss, gaze paresisparesis
• Pons (5-12%)Pons (5-12%)• Quadriparesis, facial weakness, decreased level Quadriparesis, facial weakness, decreased level
consciousnessconsciousness• Cerebellum (1-5%)Cerebellum (1-5%)
• Ataxia, miosis, gaze paresisAtaxia, miosis, gaze paresis
Marc Dorfman, MD, FACEP, MACP
Other ICH EtiologiesOther ICH Etiologies• AmyloidAmyloid• TraumaTrauma• Vascular malformation-Avm, Vascular malformation-Avm,
cavernoushemangiomascavernoushemangiomas• AneurysmAneurysm• TumorTumor• CoagulopathyCoagulopathy• VasculitisVasculitis
Marc Dorfman, MD, FACEP, MACP
ICH PresentationICH Presentation
• Hypertension (90%)Hypertension (90%)• Altered mental status (50%)Altered mental status (50%)• Headache (40%) Headache (40%) • Seizures (6-7%)Seizures (6-7%)
ICH DiagnosisICH Diagnosis
• CT scanCT scan
CT scan is the most effective tool in the ED
CT scan is excellent for imaging blood
Marc Dorfman, MD, FACEP, MACP
ICH Rx Key ConceptsICH 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
Marc Dorfman, MD, FACEP, MACP
Increased ICP TreatmentIncreased ICP Treatment• Intracranial Pressure (ICP): Intracranial Pressure (ICP):
considered a major contributor to considered a major contributor to mortality when elevatedmortality when elevated
• Controlling ICP is considered Controlling ICP is considered essentialessential• OsmotherapyOsmotherapy• HyperventilationHyperventilation• Barbiturate comaBarbiturate coma
Marc Dorfman, MD, FACEP, MACP
Clinical Case: ED RxClinical 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 Bed Elevate Head of Bed • Hyperventilation to pCO25-30Hyperventilation to pCO25-30
Marc Dorfman, MD, FACEP, MACP
Clinical Case: ED RxClinical Case: ED Rx• Paralytics-Pancuronium 7 mgParalytics-Pancuronium 7 mg• BP management-NiprideBP management-Nipride• Steroids-Decadron 10 mgsSteroids-Decadron 10 mgs
Marc Dorfman, MD, FACEP, MACP
OsmotherapyOsmotherapy• Osmotherapy-MannitolOsmotherapy-Mannitol
• Reduces cerebral edema by Reduces cerebral edema by decreasing cerebral fluid volumedecreasing cerebral fluid volume
• Rebound effect-use less than 5 daysRebound effect-use less than 5 days• 20% solution20% solution• 0.5-1.0 mg/kg maintain serum 0.5-1.0 mg/kg maintain serum
osmolarity 310-320 mOsm/Losmolarity 310-320 mOsm/L
Marc Dorfman, MD, FACEP, MACP
HOB ElevationHOB Elevation• Elevate head of bed-decrease ICPElevate head of bed-decrease ICP• Mechanical-helps drain blood by Mechanical-helps drain blood by
gravitygravity• Does not allow blood to pool in Does not allow blood to pool in
cranium, which may occur if patient cranium, which may occur if patient is left laying flatis left laying flat
Marc Dorfman, MD, FACEP, MACP
Endotracheal IntubationEndotracheal Intubation• Intubation-not required, but airway Intubation-not required, but airway
protection and adequate ventilation protection and adequate ventilation are necessaryare necessary• Rely on clinical suspicion, not GCSRely on clinical suspicion, not GCS• Hyperventilation decreases ICP Hyperventilation decreases ICP • pCO2 should be kept around 30-35pCO2 should be kept around 30-35• Beneficial effect of sustained Beneficial effect of sustained
hyperventilation is not provenhyperventilation is not proven
Marc Dorfman, MD, FACEP, MACP
ParalyticsParalytics• Recommended in order to prevent Recommended in order to prevent
increasing intrathoracic and venous increasing intrathoracic and venous pressures associated with pressures associated with coughing, suctioning, and bucking coughing, suctioning, and bucking on ETT, all of which may cause ICP on ETT, all of which may cause ICP spikesspikes
• ICP spikes associated with poorer ICP spikes associated with poorer outcome, especially in setting of outcome, especially in setting of elevated ICPelevated ICP
Marc Dorfman, MD, FACEP, MACP
ICP MonitorsICP Monitors• AHA recommends ICP monitors AHA recommends ICP monitors
in patients with a GCS less than 9 in patients with a GCS less than 9 and all patients whose condition and all patients whose condition is thought to be deteriorating due is thought to be deteriorating due to elevated ICPto elevated ICP
Marc Dorfman, MD, FACEP, MACP
BP ManagementBP Management• Lower blood pressure to decrease risk Lower blood pressure to decrease risk
of ongoing bleeding from ruptured of ongoing bleeding from ruptured small arteriessmall arteries
• Overaggressive treatment of blood Overaggressive treatment of blood pressure may decrease cerebral pressure may decrease cerebral perfusion pressure and worsen brain perfusion pressure and worsen brain injuryinjury
• Especially true with elevated ICPEspecially true with elevated ICP
Marc Dorfman, MD, FACEP, MACP
BP ManagementBP Management• AHA recommends blood pressure AHA recommends blood pressure
be maintained below a mean be maintained below a mean arterial pressure of 130 mm Hg in arterial pressure of 130 mm Hg in persons with a history of persons with a history of hypertensionhypertension
• 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) Cerbral perfusion pressure (MAP-ICP)
should be kept > 70 mm Hgshould be kept > 70 mm Hg
Marc Dorfman, MD, FACEP, MACP
BP ManagementBP Management• Avoid hypotensionAvoid hypotension
• If systolic BP drops to less than If systolic BP drops to less than 90 mmHg, consider judicious fluid 90 mmHg, consider judicious fluid boluses and/or start pressorsboluses and/or start pressors
Marc Dorfman, MD, FACEP, MACP
BP ManagementBP Management• LabetalolLabetalol
• 20 mg IV, followed by 40 80 mg IV q10 20 mg IV, followed by 40 80 mg IV q10 minmin
• Titrate to BP or max 300 mgs adminTitrate to BP or max 300 mgs admin• NiprideNipride• 0.5-1.0 mics/kg/min0.5-1.0 mics/kg/min
• Theoretically can increase cerebral blood Theoretically can increase cerebral blood flow and thereby intracranial pressureflow and thereby intracranial pressure
Marc Dorfman, MD, FACEP, MACP
BP ManagementBP Management• Treatment should be started within Treatment should be started within
6 hours of symptom onset6 hours of symptom onset• A Prospective Multicenter Study to A Prospective Multicenter Study to
Evaluate the Feasibility and Safety of Evaluate the Feasibility and Safety of Aggressive Antihypertensive Aggressive Antihypertensive Treatment in Patients with Acute Treatment in Patients with Acute Intracerebral HemorrhageIntracerebral 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
Marc Dorfman, MD, FACEP, MACP
Fever ManagementFever Management• Elevated temperatures can increase the Elevated temperatures can increase the
degree of ischemic injury. degree of ischemic injury. • Etiologies include infection, neuronal Etiologies include infection, neuronal
injury, SIRSinjury, SIRS• Studies have demonstrated increased Studies have demonstrated increased
morbidity and mortality in patients with morbidity and mortality in patients with sustained temperature elevation. sustained temperature elevation.
• Treat temperture > 38.5Treat temperture > 38.5˚̊ C C• Acetaminophen or a cooling blanket best Acetaminophen or a cooling blanket best
options. options.
Marc Dorfman, MD, FACEP, MACP
Seizure TherapySeizure Therapy• Neuronal injury may lead to seizuresNeuronal injury may lead to seizures• Nonconvulsive seizures may contribute Nonconvulsive seizures may contribute
to coma in up to 10% of neurocritical to coma in up to 10% of neurocritical patientspatients
• Consider prophylactic antiepileptic Consider prophylactic antiepileptic therapy in setting of ICHtherapy in setting of ICH• Lobar hemorrhage-35% seizure rateLobar hemorrhage-35% seizure rate
• Fosphenytoin or phenytoinFosphenytoin or phenytoin
Marc Dorfman, MD, FACEP, MACP
Medical TherapyMedical 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
Marc Dorfman, MD, FACEP, MACP
Blood ClotBlood Clot
Marc Dorfman, MD, FACEP, MACP
ICH Hemorrhage GrowthICH Hemorrhage Growth
• Until recently, bleeding in patients Until recently, bleeding in patients with ICH was thought to be with ICH was thought to be completed within minutes of onsetcompleted within minutes of onset
• Several small studies describe a few Several small studies describe a few patients who had an increase in the patients who had an increase in the volume of parenchymal hemorrhage volume of parenchymal hemorrhage on repeated CT scanson repeated CT scans
Marc Dorfman, MD, FACEP, MACP
ICH Hemorrhage VolumeICH Hemorrhage Volume• Old concept-Hemorrhage static Old concept-Hemorrhage static
process; bleeding complete in a process; bleeding complete in a minutesminutes
• New concept-Hemorrhage is New concept-Hemorrhage is dynamic; process continues for dynamic; process continues for several hoursseveral hours
Marc Dorfman, MD, FACEP, MACP
ICH Hemorrhage GrowthICH Hemorrhage Growth• Early Hemorrhage Growth in Early Hemorrhage Growth in
Patients With Intracerbral Patients With Intracerbral HemorrhageHemorrhage
• Brott, Broderick, KothariBrott, Broderick, Kothari• Stroke Vol 28, 1 January 1998Stroke Vol 28, 1 January 1998
Marc Dorfman, MD, FACEP, MACP
ICH Growth: Study PurposeICH Growth: Study Purpose
• Prospectively determine how Prospectively determine how frequently early growth of frequently early growth of intracerebral hemorrhage intracerebral hemorrhage occurs and whether this early occurs and whether this early growth is related to growth is related to neurological deteriorationneurological deterioration
Marc Dorfman, MD, FACEP, MACP
ICH Growth Study DesignICH Growth Study Design• 102 patients102 patients• CT scan 3 hours and 24 hoursCT scan 3 hours and 24 hours• 38% patients with > 33% growth 38% patients with > 33% growth
in volume of parenchymal in volume of parenchymal hemorrhagehemorrhage
Marc Dorfman, MD, FACEP, MACP
ICH Growth: Conclusions ICH Growth: Conclusions • Substantial early hemorrhage growth in Substantial early hemorrhage growth in
patients with with intracerebral patients with with intracerebral hemorrhage is common and is hemorrhage is common and is associated with neurological associated with neurological deterioration.deterioration.
• Randomized treatment trials are Randomized treatment trials are needed to determine whether this needed to determine whether this ongoing bleeding and frequent ongoing bleeding and frequent neurological deterioration can be neurological deterioration can be improvedimproved
Marc Dorfman, MD, FACEP, MACP
ICH Factor VIIa StudyICH Factor VIIa Study• Safety and Feasibility of Safety and Feasibility of
Recombinant Factor VIIa for Recombinant Factor VIIa for Acute Intracerebral HemorrhageAcute Intracerebral Hemorrhage
• Mayer, Nikolai, BrunMayer, Nikolai, Brun• StrokeStroke, Jan 2005, 36(1) p74-9, Jan 2005, 36(1) p74-9
Marc Dorfman, MD, FACEP, MACP
ICH Factor VIIa Study PurposeICH Factor VIIa Study Purpose
• Factor VIIa-promotes clotting-Factor VIIa-promotes clotting-know to do so in hemophiliacsknow to do so in hemophiliacs
• Activated factor VII promotes Activated factor VII promotes hemostasis at sites of vascualr hemostasis at sites of vascualr injury and may minimize injury and may minimize hematoma grwoth in ICHhematoma grwoth in ICH
Marc Dorfman, MD, FACEP, MACP
ICH Factor VIIa Study DesignICH Factor VIIa Study Design
• 48 subjects48 subjects• Randomized double blind Randomized double blind
placebo controlledplacebo controlled• Escalating doses of factor VIIEscalating doses of factor VII• Endpoint-frequency of adverse Endpoint-frequency of adverse
eventsevents
Marc Dorfman, MD, FACEP, MACP
ICH Factor VIIa Study ConclusionICH Factor VIIa Study Conclusion
• Phase II trialPhase II trial• No major safety concernsNo major safety concerns• Larger study needed to Larger study needed to
determine if factor VII can safely determine if factor VII can safely and effectively limit ICH growthand effectively limit ICH growth
Marc Dorfman, MD, FACEP, MACP
ED Patient ManagementED Patient Management• Neurosurgery consultedNeurosurgery consulted• EVD placed in the EDEVD placed in the ED• Patient taken to the OR for Patient taken to the OR for
evacuation of hematomaevacuation of hematoma• BP-119/79 P-92 RR-12BP-119/79 P-92 RR-12
Marc Dorfman, MD, FACEP, MACP
Patient OutcomePatient Outcome
• Next day: brain flow studiesNext day: brain flow studies• Patient declared brain deadPatient declared brain dead• Patient extubatedPatient extubated
Marc Dorfman, MD, FACEP, MACP
ICH Surgical IndicationsICH Surgical Indications• Cerebellar hemorrhage > 3 cm who are Cerebellar hemorrhage > 3 cm who are
deteriorating or with brain stem deteriorating or with brain stem compression and hydrocephalus from compression and hydrocephalus from ventricular obstructionventricular obstruction
• Vascular malformation if lesion is Vascular malformation if lesion is surgically accessible and patient has surgically accessible and patient has chance for good outcomechance for good outcome
• Young patients with a moderate or Young patients with a moderate or large lobar hemorrhage who are large lobar hemorrhage who are clinically deterioratingclinically deteriorating
Marc Dorfman, MD, FACEP, MACP
Non-Surgical ICH PtsNon-Surgical ICH Pts• Small Hemorrhages (10 cmSmall Hemorrhages (10 cm33))• Minimal neurological deficitsMinimal neurological deficits• GCS < 4 (excluding cerebellar GCS < 4 (excluding cerebellar
hemorrhage with brain stem hemorrhage with brain stem compression)compression)
Marc Dorfman, MD, FACEP, MACP
Key Learning PointsKey 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 CT scan is the most important tool in your
diagnostic toolboxdiagnostic toolbox• Manage blood pressure, noting that guidelines Manage blood pressure, noting that guidelines
are variableare variable• Aggressively manage fever and seizuresAggressively manage fever and seizures• Consider hyperventilation and paralytics in Consider hyperventilation and paralytics in
setting of increased ICP and deteriorationsetting of increased ICP and deterioration
Marc Dorfman, MD, FACEP, MACP
Key Learning PointsKey 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 There are promising new therapies
such as Factor VII on the horizonsuch as Factor VII on the horizon
Questions??Questions??
[email protected]@ferne.org
Marc Dorfman, MDMarc Dorfman, [email protected]
773 792 7921773 792 7921
ferne_aaem2005_dorfman_ich_cdformat.ppt 2/14/2005 7:02 PM
Marc Dorfman, MD, FACEP, MACP