MANAGEMENT OF INTRACEREBRAL HEMORRHAGENavaz Karanjia, MD

Director of Neurocritical Care

University of California – San Diego

Intracerebral Hemorrhage

Intracerebral Hemorrhage

Intracerebral Hemorrhage

Neurocritical Care Management of Intracerebral Hemorrhage Epidemiology

10-15% of all strokes, 50-70,000 cases/yr in US Presentation

Headache, neurologic deficit Outcomes

40% 30-day mortality Reduced by 17% by an NCCU/neurointensivist

20% independent at 6 monthsImproves by 21% by an NCCU/neurointensivist

Mirski M, Chang CW, and Cowan R. J Nsurg Anesth 2001; 13(2): 83-92.

Lancet Neurol. 2010 Feb;9(2):167-76. doi: 10.1016/S1474-4422(09)70340-0

Intracerebral Hemorrhage

Causes of ICH

Intracerebral Hemorrhage

Common locations for hypertensive ICH

Thalamus Cerebellum Pons Basal Ganglia

Intracerebral Hemorrhage

Clinical course and complications

Tissue dissection, displacement, increased ICP (immediate)

Hematoma expansion (immediate ->36h)HydrocephalusNeurohemoinflammation/Cerebral edema (day 2-5)SeizuresCentral fever

Intracerebral Hemorrhage

Hematoma expansion72% have some hematoma expansion over 24h

38% have clinically significant expansion within 24h

Within 1 hr in 26% of casesWorsens outcome

Neurocritical Care Management of Intracerebral Hemorrhage Preventing hematoma expansion (INTERACT,

ATACH) IMMEDIATE BP control reduces expansion 30%

Target SBP 140-150 with nicardipine drip or labetalol/hydralazine IVP WITHIN 10 MINUTES

IMMEDIATE coagulopathy reversal FFP, PCC (KCentra) within 30 minRecheck coags 15 min post PCCPlatelets if <100,000 or TEG abnlNOT factor VII (FAST trial)Time to reversal is being tracked

PCC (Profilnine) Pathway

History of thrombotic event in past 6 wks? (DVT, PE, trauma, ischemic stroke, ACS, mesenteric ischemia, etc)Major surgery within 6 weeks? Heparin induced thrombocytopenia (HIT)?

UCSD Reversal Protocol for Spontaneous Intracerebral Hemorrhage with INR > 1.4

• INR 2-4: infuse 25 units/kg body weight* Profilnine over 5 min, not to exceed 2ml/min

• INR >4: infuse 40 units/kg body weight* Profilnine over 10 minutes, not to exceed 2ml/min

• Repeat INR 15 minutes after infusion complete. If INR not at target, repeat q15 min x2 until INR at target. Once INR ≤1.4, repeat INR every 6 hrs for 24 hrs. If INR > 145, give another 10mg vitamin K IV/PO and consider 2 more units FFP.

• If INR does not reach target in 45 minutes, consider Factor 7, 20-40 mcg/kg (1-3mg) IV x 1

At 24 hrs, repeat dose of Vitamin K 10 mg IV/PO * in obese patients, base dose on a maximum weight of ideal body weight + 20% ***

Check the following labs at 1 hr and q6 hrs after completion of PCC infusion: PT/INR, EKG and Cardiac enzymes, Fibrinogen

INR > 2.0

• STAT Labs: PT/INR, PTT, fibrinogen, platelets, CBC, Type and Screen, troponin• If crash craniotomy considered, type and cross 2U PRBC

• Give vitamin K 10mg IV stat; if IV not available, give 10mg PO• Transfuse 2U FFP stat over 30 min. If type&screen will take >30 min and INR>2, transfuse 2U

uncrossmatched FFP. If pt cannot tolerate FFP due to volume overload, use PCC+Factor 7 20-40mcg/kg (1-3 mg)

FFP Pathway

• Immediately give 2 more units FFP • Repeat coags upon completion of infusion• If INR still >1.4, 2 more units FFP • If still > 1.4, consider PCC and consult hematology• Once INR ≤1.4, repeat INR q4-6 hrs for 24-48 hrs

Can patient tolerate more FFP (volume status)?YES

NO YES

INR 1.4 – 2.0

NO

Stat labs at 15 min and q6 hours after completion of PCC infusion: PT/INR, TT, EKG, cardiac enzymes, fibrinogen, anti-Xa level. If TT or PT/INR is still prolonged AND patient still bleeding/extreme risk of hematoma expansion, consider repeating Profilnine dose or giving Factor 7, 20-40mcg/kg (1-3mg) IV x1

UCSD Reversal Protocol for Spontaneous Intracerebral Hemorrhage on Dabigatran, Rivaraoxaban, or Apixaban

• STAT labs: PT/INR, fibrinogen, platelets, CBC, PTT, TT, anti-Xa level , Type & Screen• If crash craniotomy considered, type and cross 2U PRBC

IF ON DABIGATRAN (direct thrombin inhibitor )

and TT prolongedIF ON RIVAROXABAN or APIXABAN (factor Xa inhibitor)

and PT/INR is prolonged or anti-Xa level elevated

IF ingestion within 2 hrs, give one dose activated charcoal orally

• infuse 25 units/kg (+/- 10%) body weight* PCC (Profilnine) over 5 minutes, not to exceed 2ml/min• Transfuse 2 units FFP STAT. If type and screen will take >30 min, transfuse 2 units uncrossmatched FFP.

Emergent dialysis may be considered in certain circumstances (renal failure, overdose); ~ 65% removed by hemodialysis

Dabigatran t ½ = 14 hrs (up to 34 hrs in severe renal impairment)

Rivaroxaban and Apixaban are NOT dialyzable

Rivaroxaban t 1/2 = 9 hrs (longer in renal impairment)Apixaban t ½ = 12 hrs (longer in renal impairment)

* in obese patients, use maximum weight of ideal body weight + 20%

Neurocritical Care Management of Intracerebral Hemorrhage Acute obstructive hydrocephalus

occurs in 50-70% of IVH patients treat with emergent EVD Intraventricular tPA for IVH clears IVH faster (11.4-

>2.6 days), likely reduces hydrocephalus/need for VP shunt, ? mortality/outcomes (CLEAR-IVH)

Huttner HB, Tognoni E et al. Eur J Neurol. 2008;15(4):342.

Intracerebral Hemorrhage

Neurohemoinflammation/cerebral edemaPeaks days 2-5Exacerbated by fever and seizureMedical cerebral edema treatment ((hypertonic saline, normothermia, seizure control, ventilation control)

Surgical/endoscopic clot removal

Neurocritical Care Management of Intracerebral HemorrhageSurgical clot removal (MISTIE II, STICH II trials)Endoscopic for deep clots

Improves good outcome 20% 34%

Open for all superficial clotsReduces mortality (STICH II)

Neurocritical Care Management of Intracerebral Hemorrhage

MISTIE II

Hanley, D et al. Mistie II Trial Results: 365 day outcome and cost-benefit. ISC 2013 Late Breaking Newshttp://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_449055.pdf

Seizure control33% of altered ICH patients have seizures, most are nonconvulsiveSeizures worsen ICP, midline shiftAll altered ICH pts should receive

continuous EEG monitoring (Class I, LOE B )

Claassen et al. Anesthesia Analg. Vol. 109, No. 2, August 2009

2012 Neurocritical Care Society Guidelines:

Indications for Continuous EEG

Monitoring

Neurocritical Care Management of Intracerebral Hemorrhage

Neurocritical Care Management of Intracerebral Hemorrhage

Vespa et al Neurology 2003

Seizures after ICH leads to worsening midline shift

Neurocritical Care Management of Intracerebral Hemorrhage

Vespa et al Neurology 2003

Seizures after ICH leads to worsening midline shift

Neurocritical Care Management of Intracerebral Hemorrhage

Vespa et al Neurology 2003

Seizures after ICH leads to worsening midline shift

Intracerebral Hemorrhage

Antiepileptics are indicated ONLY if the patient demonstrates evidence of seizure clinically or on EEG (prophylactic AED’s worsen outcome, OR mRS>3 = 9.8).

Class I, LOE B

AED PROPHYLAXIS?

Naidech et al, Stroke 2009

Intracerebral Hemorrhage

Central feverOccurs in 70% of patientsIncreases cerebral metabolic rate, ICP, and midline shiftNormothermia should be maintained and fever treated aggressively, using antipyretics and intravascular/surface cooling devices if needed (Class I, LOE B recommendation)

Neurocritical Care Management of Intracerebral Hemorrhage

Normothermia, glycemic control, dysphagia screening

Lancet 2011: For all hemorrhagic and ischemic stroke patients, implementation of an RN protocol to treat any temp≥37.5, glycemic control, dysphagia screening decreases death/dependence 58% -> 42%, NNT 6.4

Intracerebral Hemorrhage

Neurocritical Care Management of Intracerebral Hemorrhage