1. Intracerebral Haemorrhage
Dr Nishantha Gunasekera
MBBS, MS, MRCS
Consultant Neurosurgeon
Department of Neurosurgery
Teaching Hospital
Karapitiya Ruhunu Clinical Society Meeting
November 2012
2. Intracerebral Haemorrhage
• Second most common form of stroke (15-30%)
• Onset smooth and progressive – unlike ischeamic stroke
• Unenhanced CT brain -1st investigation
• Volume correlates to mortality, morbidity (Modified Elipsoid Volume = axbxc/2)
• Clot enlarges in ~33% of cases within 3 hours
• Angiography recommended (except >45y, thalamic, putamen,
post.fossa ICH)
• F VIIa given within 4 hrs to limit volume
• Role of surgery
3. Intracerebral Haemorrhage
• Epidemiology /risk factors
• 12-15/100,000 per year
• Twice the incidence of SAH
• Incidence increases after 55yrs.
• Doubles with each decade till 80yrs and after 80yrs, 25
times the previous decade
• More common in men
• Previous CVA (any) increases risk 23:1
• Alcohol (>3 drinks a day increases risk ~x7)
• Smoking ?
• Liver dysfunction
7. Intracerebral Haemorrhage
• Aetiologies cntd..
8. Venous/dural sinus thrombosis
9. Drug related
10. Post trumatic
11. Pregnancy related (post partum angiopathy)
12. Post Operative
13. Idiopathic
8. Intracerebral Haemorrhage
History Comment
Time of onset (time the patient was last
normal)
Vascular risk factors Hypertension, diabetes, hypercholesterolae
mia, smoking
Medications Anticoagulants, antiplatelets, decongestants
, antihypertensives, stimulants, sympathomi
metics
Recent trauma or surgery Carotid endarterectomy or carotid stenting
in particular as ICH may be related to
hyperperfusion after such procedures.
Traumatic aneurysms!
Dementia Associated with amyloid angiopathy
Alcohol or illicit drug use Cocaine and other sympathomimetic drugs
are associated with ICH, stimulants
Seizures
Liver disease coagulopathy
Cancer and haematologic disorders coagulopathy
9. Intracerebral Haemorrhage
Physical Examination Comments
Vital signs Fever associated with early neurologic
deterioration (?aspiration)
Higher initial BP associated with early
deterioration and higher mortality
A general physical exam focusing on head, ?trauma
heart, lungs, abdomen and extremities
A thorough but time urgent neurologic A structured exam such as the National
exam Institutes of Health Stroke Scale (NIHSS)
can be completed in minutes and
provides a quantification that allows easy
communication of severity of the event to
care givers.
We use the Glasgow Coma Scale whose
initial score is a strong predictor of
outcome
10. Intracerebral Haemorrhage
• Microaneurysms of Charcot-Bouchard
– AKA milliary aneurysms
– From small branches of the lateral lenticulo-striate arteries
in basal ganglia
– Possible origin of the “hypertensive ICH” of basal ganglia
11. Intracerbral Haemorrhage
• Cereberal Amyloid Angiopathy (CAA)
– AKA Congophilic angiopathy
– Present in >50% of patients >70yrs
– May present with a TIA like prodrome
– Suspect in patients with recurrent ICHs
– Lobar in location
– Gradient echo MRI will identify small haemorrhages or
haemosiderin in cortical areas
– Pathogenic deposits of Beta Amyloid Protein
(“apple green” birefringence under polarised light)
12. Intracerebral Haemorrhage
ICH Score (Hemphill et al.)
Feature Finding Points ICH Score 30 Day
Mortality
GCS 3-4 2
5-12 1 0 0%
13-15 0
1 13%
Age >=80 1
<80 0 2 26%
Location Infratentorial 1
Supratentorial 0 3 72%
ICH volume >=30cc 1
4 97%
<30cc 0
Intraventricular Yes 1
5 100%
Blood
No 0 6 100%
ICH SCORE 0-6 points
13. Intracerebral Haemorrhage
Thinking About Interventions
• Class I evidence
Conditions for which there is evidence for and general agreement that the
procedure or treatment is useful and effective
• Class II evidence
Conditions for which there is conflicting evidence and divergence of opinion
about usefulness and effectiveness of the procedure/treatment
• Class III evidence
Conditons for which there is evidence and general agreement that the procedure
or treatment is NOT useful or effective and in some cases may be harmful
14. Intracerebral Haemorrhage
Therapeutic recommendations
Level of evidence A Data from MRCT
Level of evidence B Data from SRCT
Level of evidence C Consensus of opinion of experts,
case studies or standard of care
MRCT- Multiple Randomized Clinical Trials (meta-analyses)
SRCT – Single Randomized Clinical Trial
15. Intracerebral Haemorrhage
Diagnostic Recommendations
Level of Evidence A Data from prospective cohort
studies using a reference
standard applied by a masked
evaluator
Level of Evidence B Data from one or more case
control studies or studies using a
reference standard applied by an
unmasked evaluator
Level of Evidence C Consensus of opinion of Experts
19. Intracerebral Haemorrhage
• Rapid neuroimaging with CT or MRI is recommended to
distinguish ischaemic stroke from ICH- Class I
• CT angiography and contrast CT maybe considered to help
identify patients at risk for haematoma expansion – Class II
• CT angiography, CT venography, C+CT, C+MRI, MTA, MRV
maybe useful to identify structural lesions (AVM, Tumour) –
Class II
20. Intracerebral Haemorrhage
• Spot sign
Contrast extravasates into ICH
May predict expansion of ICH
Delgado Almadoz et al. Stroke,40(9):2994.2009
21. Intracerebral Haemorrhag
• Anticoagulation and ICH
Leads to more Haematoma growth and higher mortality
- Reverse warfarin promptly and aggressively
- FFP or Prothrombin Complex Concentrates (PCC eg.novo VII )
- IV vitamin K
Patients with sever coagulation factor deficiency or severe
thrombocytopaenia should receive appropriate factor replacement
therapy or platelets, respectively
Class I, Evidence C
22. Intracerebral Haemorrhage
• Patients with elevated INR due to OAC should have there
warfarin withheld , receive therapy to replace vitamin K-
dependent factors and correct INR and receive Intravenous
vitamin K
Class I, Evidence C
• PCC have not shown improved outcomes compared with FFP
but may have fewer complications compared with FFP and are
reasonable to consider as an alternative to FFP
Class II, Evidence B
23. Intracerebral Haemorrhage
• The usefulness of platelet transfusion in ICH patients with a
history of antiplatelet use is unclear and is considered
investigational
Class II, Evidence B
• Practically we still do it despite the lack of platelet function
tests
24. Intracerebral Haemorrhage
• Haematoma Expansion
– Common
– 103 pts. Prospective observation study with serial CTs
(baseline, 1hr and 20 hrs following ICH)
– 26% showed > 33% enlargement on 1hr CT
– 38% showed> 33% enlargement on 20 hr CT
– Neurological deterioration correlated with haematoma
expansion
Brott T et al, Stroke.1997 Jan;28(1):1-5
25. Intracerebral Haemorrhage
• Hypertension and ICH
– INTERACT trial (Intensive Blood Pressure Reduction in Acute Cerebral
Hemorrhage)
• 404 patients randomized into
» Target SBP of 140mmHg within 1 hr or
» Target SBP of 180mmHg
– Trend toward lower haematoma growth in the lower
BP group
– No increase in adverse events related to lower BP
Anderson CS, et al. Lancet Neurol.2008;7(5):391-399.
26. Intracerebral Haemorrhage
– ATACH (Antihypertensive Treatment for Acute Cerebral Haemorrhage)
• 80 ICH pts.
• 4-tier, dose escalation of IV Nicardipine based lowering
of BP
• Confirmed safety and feasibility of early rapid BP
lowering
Qureshi Al.et al, for the ATACH Investigators Arch Neurol.2010May;67(5):570-6
27. Intracerebral Haemorrhage
Until ongoing clinical trials of BP intervention for ICH
are completed, physicians must manage BP on the
basis of the present incomplete efficacy evidence
Class II, Evidence C
In patients presenting with a systolic BP of 150-220
mmHg, acute lowering of SBP to 140mmgHg is
probably safe
Class II, Evidence B
28. Intracerebral Haemorrhage
• Recommended BP Treatment Targets
– If SBP >200mmHG or MAP >150mmHg
• then consider aggressive reduction of BP with continuous IV
infusion, with frequent BP monitoring every 5 mins
– If SBP > 180mmHg or MAP >130mmHg and there is a
possibility of raised ICP
• then consider monitoring ICP and reducing BP using intermittent or
continuous IV meds. while maintaining CPP > 60mmHg
29. Intracerebral Haemorrhage
– If SBP is >180mmHg or MAP is >130 and there is
NO evidence of raised ICP
• Then consider modest reduction of BP (eg. MAP 110,
BP 160/90) using intermittent or continuous IV meds.
while clinically examining the patient every 15 mins.
30. Intracerebral Haemorrhage
• Other Medical Considerations
– Initial management and monitoring in an ICU with
physician and intensivist
– Glucose should be monitored and normoglycaemia
recommended
– Intermittent pneumatic compression of calves
– Clinical seizures treated with antiepileptics
– Prophylactic antiepileptics NOT recommended
31. Intracerebral Haemorrhage
• Hydrocephalus
– May accompany ICH especially
if intraventricular rupture
– Elevates ICP
– Results in early or delayed
neurological deterioration
– Surgery for evacuation of IVH/treatment
of ventriculomegally
33. Intracerebral Haemorrhage
• Surgical Treatment of ICH
– STICH trial (Surgical Treatment of Intracerebral Haemorrhage)
Newcastle group
– 902 ICH pts. randomized for early evacuation (<96hrs) vs
medical management
– Excluded cerebellar ICH
– Only considered cases falling within the “uncertainty
group”
– Uncertainty group = group of patients for whom EITHER
medical or surgical management would be considered
35. Intracerebral Haemorrhage
• If ICH >1cm from the cortical surface or GCS< 8
– Surgical patients tended to do worse than medical patients
• If ICH <1cm from the surface
– Patients tended to towards better outcomes with surgery but
not significant (OR 0.69, 95%)
36. Intracerebral Haemorrhage
• The Lancet, Volume 365, Issue 9457, Pages 387 - 397, 29 January 2005
• Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral
haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial
• Original Text
• Prof A David Mendelow , Barbara A Gregson , Helen M Fernandes , Gordon D Murray , Graham M Teasdale , D
Terence Hope , Abbas Karimi , M Donald M Shaw , David H Barer , for the STICH investigatorsInvestigators listed at
the end of report
Selection
Patients were eligible for inclusion if they had CT evidence of a
spontaneous supratentorial intracerebral haemorrrhage that
had arisen within 72 hours and if the responsible
neurosurgeon was UNCERTAIN about the benefits of either
treatment (clinical uncertainty principle)
Interpretation
Patients with spontaneous supratentorial intracerebral haemorrhage in
neurosurgical units show no overall benefit from early surgery when
compared with initial conservative treatment.
37. Intracerebral Haemorrhage
• Surgical Management of ICH
– For patients presenting with supratentorial lobar
clots > 30 cc within 1cm of the surface, with
clinical deterioration, evacuation via craniotomy
is standard
– For stable patients with smaller clots, surgery may
be considered only if clinical deterioration occurs
while under observation
41. Intracerebral Haemorrhage
• Patients with cerebellar haemorrhage who are deteriorating or
who have brain stem compression and or hydrocephalus
should under go evacuation/ EVD as soon as possible
• Ultra early removal of supratentorial ICH may not be safe due
to ongoing bleeding
• Minimally invasive clot evacuation is not standard and
considered investigational
42. Intracerebral Haemorrhage
• Risk factors for Recurrence
– Lobar ICH
– Older age
– Anticoagulation
– Apo E e2 or e4 alleles
– Increased number of Microbleeds on MRI
43. Intracerebral Haemorrhage
• Prevention of Recurrence
– BP should be very well controlled particularly for patients
with ICH location typical of hypernensive vasculopathy
– Target of less than 140/90 (130/80 if diabetic or has CRD)
is reasonable
– Avoid long term anti-platelet drugs / anticoagulation
without proper indications and follow up.
• Every one gets aspirin/ clopidogrel etc etc!!
44. Intracerebral haemorrhage
• Rehabilitation and Recovery
– Multidisciplinary
– As early as possible
– Well coordinate “seamless” accelerated hospital discharge
– Home based re-settlement
