Epidemiologic features
Incidence10~20 cases per 100,000Increases with ageMen, especially older than 55 years oldBlacks and JapaneseHypertension the most important !Cerebral Hemorrhage
Up to 50%, 30 day mortality Little effective therapyICH – Worse Outcomes Than Ischemic Stroke 1. American Heart Association. Heart Disease and Stroke Statistics-2005 Update; 2. Qureshi AI. et al. N Engl J Med. 2001;344:1450-1460; 3. Broderick JP. et al. Stroke. 1999;30:905-915; 4. Broderick JP. et al. N Engl J Med. 1992;326:733-736
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ICH
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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.
Sites of Intracerebral Hemorrhage
Quereshi et al. N Engl J Med. 2001;344:1450-60Hypertensive Intracerebral Hem: Sites
1. Putamen-Claustrum 2. Cerebral white matter 3. Thalamus 4. Pons 5. Cerebellum55% 15 10 10 10
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 growthHematoma Growth
Hematomas expand on serial CT 38% <24 hours Continued bleeding or rebleeding Adverse prognosisSilva et al. Stroke. 2005
Adverse Prognostic Factors
Old age Large hematoma volume Hematoma growth & increase with time Low GCS Intraventricular bleeding or extension Infratentorial siteHemorrhage and Volume
Expect good recovery for small volume less than 10 ml Mortality 90% for comatose patients with large volume more than 60 ml3 hours
Hematoma Growth9 hours
6.5 hours after onset2.0 hours after onset
Symptoms
Change level of consciousness Apathetic Lethargy Sleepiness Stupor Coma & Unconsciousness *Headache Nausea or vomiting Hemiplegia or hemiparesis Hemihypesthesia
DiagnosisCT scan infarction or hemorrhageLocation and size of the hematomaPresence of ventricular extension Hydrocephalus
Diagnosis
Conventional angiography for secondary cause of ICH ( AVM, aneurysm..)MRI, MRA sensitivity ?Diagnosis
Complete blood count (CBC) & Platelet count Bleeding time Blood clotting tests (Prothrombin time or partial thromboplastin time) Liver function tests & Kidney function testsMedical Management of Acute ICH
ManagementEvaluation & management Hyperventilation, Oxygen Head elevation 30 degree
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 effectYu YL. et al. Stroke. 1992; 23:967 Cruz J. et al. Neurosurgery. 2002; 51:628
Mass effect & intracranial hypertensionHematoma, edema tissue, obstructive hydrocephalus herniation ! Use of hyperventilation and osmotic agent improved the long-term outcome Management
Management
Intensive monitoring of neurologic & cardiovascular status Instability is highest during the first 24 hrs GCS, hourly BPICH: 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
ICH: Blood Pressure Management
Management of blood pressureElevation of blood pressure expansion of hematoma poor outcome !BP ReductionPotential benefits: May ameliorate local edemaMay limit early hematoma growthPotential risk: Aggravation of perilesional ischemiaOPTION: Maintain MAP <130 mm HgAggressive option: MAP ≤105 mm Hg Broderick et al. Stroke. 1999;30:905
ICH: Blood Pressure Management
BP Reduction: preferred IV agents Labetolol or esmolol (b blockers) Nicardipine (CCB) Fenoldopam (dopamine agonist) Best to avoid NitroprussideRose J. and Mayer SA. Neurocritical Care. 2004;1:287
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 ICPPassero S. et al. Epilepsia. 2002;43:1175
Seizures and recurrent hemorrhageMost seizure within 24 hrsAnticonvulsants discontinued after the first month if no seizure.Seizures more than 2 weeks at risk of further seizure long-term treatment.
Surgical Management of ICH
Ventricular DrainageHydrocephalus is an independent predictor of poor outcome External drainage is associated with a 25% improved survival rate
U. Of Michigan Stroke Program
Cerebellar HematomaCan be approached with minor damageDecompression of brain stemSurgical GCS less than 14, volume > 40 mlSurgery
U. Of Michigan Stroke ProgramGoals of Surgery for ICH
Prevent herniation Improve functional outcomeU. Of Michigan Stroke Program
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.Complications
Hydrocephalus Fluid build-up in the brai Loss of cognitive function & Vision loss Permanent neurological deficit Surgery complicationsSubarachnoid Hemorrhage (SAH)
Causes of SAHRupture of an existing aneurysm 85% anteriorly Especially the anterior communicating artery Aneurismal size often >7mm and Rupture of an AV malformation Trauma Tumor
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
subhyaloid hemorrhages
Lumbar punctureHx,PE:(+), CT(-) Xanthochromia: hemoglobin--> oxyhemoglobin (reddish pink) bilirubin (yellow): 12 hr centrifuged--> spectrophotometry Sensitivity: (12hr~2wk)