Intracranial Haemorrhage

Barbara Stanley FRCA Consultant Neuroanaesthetist

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Where to start??

• Intracranial hemorrhage (MeSH term) + 2010 – 2014 = 4839

• Review articles only = 246 • Each type of bleed – last 5 years on PubMed

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Types of Haemorrhage

• EDH – 1 - 4% of TBI up to 15% post mortem series• SDH – Acute (up to 72hrs) – 30% severe TBI and

chronic (2-3 weeks) 7.35% of 70-79yr olds• ICH – 24.6/100,000 – 1 month mortality 40%.

Only 12-39% live independently. Best outcomes = Japan

• SAH – 10-15/100,000 higher Finland/Japan lower China. 50% die, 30% survivors remain dependent

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EDH

• 30 cm3 = Surgical Evacuation• <30cm3 + <5cm midline shift + < 15mm

thickest part AND GCS > 8 with NO FOCAL DEFICIT = serial CT + observe in Neurosurgical unit

– BTF Guidelines http://tbiguidelines.org/glHome.aspx?gl=3

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• Extradural haematoma—To evacuate or not? Revisiting treatment guidelines Z. Zakaria et al. Clinical Neurology and Neurosurgery 115 (2013) 1201–1205– 3 cases– 2 large (>30cm3) EDH’s managed conservatively = good

outcomes – 1 large EDH surgically evacuated = poor outcome– Excellent summary of current literature on EDH and

existing controversies

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28yr old. Fall. CT scan showed a large EDH in the right parieto-occipital region with a MLS of 5mm(Fig. 1a). Small temporal contusions were also noted on the scan. The blood volume was 90cm3. He was admitted for neurologic observation and analgesics were administered. After a few hours, his symptoms receded, and 24 h later he remained well. A repeat CT scan showed no change in the features of the EDH.

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56 man. Fall. GCS 7/15 fixed midsize pupils. 30 cm3 clot overlaying transverse sinus. Hydrocephalus. EVD and VP shunt. Full recovery

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52 man. Collapse. GCS 14/15 then 6/15. 130cm3 Rt EDH clot with 1mm shift evacuated. Dense Rt hemiplegia with GCS 13/15 outcome = Kernahon’s Notch phenomenon.

Acute SDH

• >10mm thick or >5mm shift = surgical evacuation regardless of GCS

• <10mm thick + <5mm shift operate if GCS <9 AND/OR:– GCS drop by 2 between injury + admission– Pupils fixed dilated– ICP >20

– BTF Guidelines: http://tbiguidelines.org/glHome.aspx?gl=3

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SDH• Mortality uncomplicated ASDH = 20% but up

to 50% and even 70% in some studies (Taussky et al 2008)

• Why so bad?

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GOS 4 + 5GOS 3GOS 1 + 2

anisocoreareactive

anisocorereactive

isocorereactive

100%

80%

60%

40%

20%

0%

Pupil reactivity on initial assessment

(Taussky et al 2008)

Age and initial GCS also predict outcome

Decompressive Craniectomy• Depends on how you class a “favourable” outcome: – Ischaemic stroke- improves survival BUT analysis of

European Stroke Trials classed modified Rankin Score 4 as favourable (Vahedi et al Lancet 2007)

– Meta analysis increases chance survival with unfavourable outcome

– TBI – No evidence increased chance of survival with favourable or unfavourable outcome – studies are heterogenous (Honeybul & Ho 2013)

– DECRA – early DC for ICP > 20 for 15mins. Outcomes worse in surgical arm @6/12

– Also has high morbidity/ complication rate

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Chronic SDH

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CSDH• Mortality around 13%• Craniostomy (Burr holes) 1st line mx +

morbidity higher in craniotomy• Drain = less recurrence (Weigel et 2003)

• 2 Burr holes better than 1 – less infection + shorter hospital stay (Smith et al 2012)

• Significant correlation exists between initial GCS and GOS after burr hole (Amirjamshidi et al 2007)

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CSDH > 90yrs

• 2 recent papers: • Stippler et al 2013. 21 pts >90yrs. 16 (76%) =

surgery (craniotomy or burr hole) 5 were observed. Surgical group =31% died. 31% nursing home. 13% rehab. 24% home

• Tabuchia et al 2014. 20 pts >90yrs. 12 (60%) burr hole under LA – rest conservative. Surgical group = 0 deaths. 66.7% home

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SAH Stroke. 2009;40:0-0

• If it has bled – secure it (Class I, Level of Evidence B).• Do it early (Class IIa, Level of Evidence B) – and in a centre where it’s

done a lot (Class IIa, Level of Evidence B). • If it’s amenable to coil or clip – coil it (Class I, Level of Evidence B) ISAT

showed endovascular coiling is associated with better outcomes at 1 year than surgical clipping if both surgeon and radiologist equally experienced

• Anaesthetists – minimise hypotension during securing(Class IIa, Level of Evidence B).

• For Vasospasm – Nimodipine (Class I, Level of Evidence A). Normovolaemia (Class IIa, Level of Evidence B). Triple H therapy (Class IIa, Level of Evidence B). Angioplasty or intraluminal vasodilators (Class IIb, Level of Evidence B).

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• Subarachnoid hemorrhage: an update for the intensivist. A. Coppadoro, G. Citerio. Minerva Anestesiol 2011;77:74-84– After five years, relative risk of death is less for patients who

have undergone coiling treatment, but no difference is demonstrated in the probability of good neurological status

– Risk of reintervention with coiling is higher than clipping– Conversely, risk of rebleeding at eight years does not appear

to be dependent on the type of treatment– Expert Committee of the American Academy of Neurology

supports the use of TCD on the basis that severe spasms can be identified with fairly high reliability.

– Emerging evidence shows CT perfusion (CTP) as the imaging technique of choice for early assessment of vasospasms. Unlike TCD it is predictive of secondary cerebral infarction

• vasopressor-induced elevation of mean arterial pressure causes a significant increase in regional cerebral blood flow and brain tissue oxygenation whereas volume expansion only slightly increased flow and reversed the positive effect on tissue oxygenation

• Clazosentan, an endothelin receptor antagonist. showed a dose-dependent reduction in angiographic vasospasms in comparison with a placebo in a recent RCT of 413 patients but is NOT SIGNIFICANT (CONSCIOUS 2)

• MASH 2 trial magnesium treatment decreased the occurrence of DCI and poor outcome but MASH 3 (phase 3 trial + metanalysis) showed no reduction in poor outcome

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• Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Dankbaar et al. Critical Care 2010, 14:R23– There is no good evidence from controlled studies

for a positive effect of triple-H or its separate components on CBF in SAH patients. In uncontrolled studies, hypertension seems to be more effective in increasing CBF than hemodilution or hypervolemia

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• Subarachnoid hemorrhage from intracranial aneurysms during pregnancy and the puerperium. Kataoka H et al. Neurol Med Chir (Tokyo). 2013;53(8):549-54

• > 50% IA ruptures occur in third trimester• Both mother and foetus benefit from surgery – maternal

mortality in surgical group 11% vs 63% in non-surgical and foetal mortality is 5% vs 27%

• If gestation >28 weeks – c-section and clipping. If not – clip whilst maintain pregnancy

• If ICP high – clot evac and EVD whilst foetal monitoring. If foetal distress – suspend ICP procedure and c-section

• Coiling – radiation absorption is low but heparinization and re-bleed risk is greater – so clipping better – but not unsafe (Endovascular treatment in pregnancy. Neurol Med Chir (Tokyo). 2013;53(8):541-8 for an excellent summary)

ICH Stroke.2010;41:2108-2129

• Rapid Imaging (Class I; Level of Evidence: A).• Control the BP if >>150 = aim for 140 (Class IIa; Level of Evidence: B).• Correct their INR (Class I; Level of Evidence: C)• PCCs have not shown improved outcome compared with

FFP but less side effects so reasonable alternative. rfVII alone not recommended for OAC reversal

• Monitor + manage in ICU (Class I; Level of Evidence: B).• Although theoretically attractive, no clear evidence at

present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding (Class III; Level of Evidence: B)

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• Surgery for Intracerebral Hemorrhage Moving Forward or Making Circles? Flaherty & Beck. Stroke.2013;44:2953-2954.

• 2 basic rationales for surgical removal of blood after. ICH.– to reduce mass effect, to improve intracranial pressure and brain perfusion

and to prevent dangerous compartment shifts and herniation– removal of blood products may reduce secondary injury caused by blood

breakdown and adverse biochemical or inflammatory processes– STICH I, published in 2005, remains the largest trial (with a sample size of

1033 subjects) to test this hypothesis) no benefit in 6-month favorable outcome in the surgical group (26%) compared with the medical group (24%, P=0.41

– subjects with lobar ICH ≤1 cm from the brain surface who underwent surgery had an 8% absolute increase in good outcomes

– STICH II – 607 patients - primary outcome of the trial, measured as favorable outcome on the Extended Glasgow Outcome Scale, did not reach statistical significance

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• a subgroup analysis on the effect of baseline prognosis (poor versus good) identified an interaction, such that subjects in the poor prognosis group randomized to surgery were more likely to have a favorable outcome than those randomized to medical care

• Subjects who were judged in need of surgery were not enrolled.• 26% of subjects randomized to medical management ultimately

crossed over to surgery. In STICH II, 21% of subjects crossed over to surgery. These subjects were typically sicker, with lower GCS scores and larger hematomas.

• If none of these patients had undergone surgery, the rates of poor outcome and death in the medical group may have been higher

• minimally invasive hematoma drainage assisted by tissue plasminogen activator infusion; the Minimally Invasive Surgery plus rtPA for Intracerebral Hemorrhage Evacuation (MISTIE) I and MISTIE II trials have been completed, and a phase III trial is being organized

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• MISTIE II trial = clot lysis through infusion rtPA via burr hole showed improved outcomes past 180 days vs medical mx. 8% rtPa group to Nhome vs 21% of medical mx and35% shorter hospital stay in rtPA ,

• Phase 3 trial onging

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• Long-term prognosis after intracerebral haemorrhage: systematic review and meta-analysis. Poon MTC, et al. J Neurol Neurosurg Psychiatry 2014;85:660–667– This systematic review and meta-analysis (>30 days) outcome

after spontaneous ‘primary’ ICH = 1-year survival was 46.0% and 5-year survival was 29.2%

– predictors of death in the long term were increasing age, decreasing Glasgow Coma Scale score, increasing ICH volume, presence of intraventricular haemorrhage and deep/infratentorial ICH location, which are the principal components of the ICH score

– Less than a half of patients with ICH survive 1 year and less than a third survive 5 years. Risks of recurrent ICH and ischaemic stroke after ICH appear similar after ICH, provoking uncertainties about the use of antithrombotic drugs.

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In Sum• If you are going to bang your head, have an EDH not an ASDH• If you’re over 65 with an ASDH your chance of being able to look after yourself without

help is about 40% (but that’s only if you’re not in the 35% who die perioperatively)• So have your clot evacuated and your Warfarin reversed• If you have a CSDH and are over 90 years old, have it in Tokyo not New Mexico• Being a girl is still a slightly risky business for SAH - especially if you smoke, drink and

have high blood pressure• Have your aneurysm coiled if possible (unless you’ve had a subdural – then have it

clipped whilst you have your clot evacuated) and your vasospasm treated with hypertension – not lots of fluids

• And if you’re pregnant try to have your SAH after 28 weeks so baby can be delivered – if not clipping provides the better occlusion – but whichever you choose – have your aneurysm secured

• Try not to have an haemorrhagic stroke – and certainly not one with a spot sign on contrast CT

• If you do then have your clot evacuated if your prognosis is poor or if it’s in your post fossa

• If your prognosis isn’t so awful – have some rTPA lysis rather than a craniotomy whilst you have your BP controlled

• And overall be managed in a centre that has experience at dealing with these things (preferably in Tokyo!!)

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• Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. R Weigel, P Schmiedek, and J Krauss. J Neurol Neurosurg Psychiatry. 2003 Jul; 74(7): 937–943

• Surgical management of chronic subdural haematoma: one hole or two? Smith MD1, Kishikova L, Norris JM. Int J Surg. 2012;10(9):450-2.

• Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience. Taussky P1, Widmer HR, Takala J, Fandino J. SWISS MED WKLY 20 08;138(19–20):281–285

• The current role of decompressive craniectomy in the management of neurological emergencies. S. Honeybul, & K. M. Ho. Brain Inj, 2013; 27(9): 979–991

• Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial . Sanne M Dorhout Mees,a,* Ale Algra,a,b W Peter Vandertop,d Fop van Kooten,e Hans AJM Kuijsten,f Jelis Boiten,g Robert J van Oostenbrugge,h Rustam Al-Shahi Salman,i Pablo M Lavados,j Gabriel JE Rinkel,a and Walter M van den Berghc Lancet. 2012 Jul 7; 380(9836): 44–49.

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• Age and Salvageability: Analysis of Outcome of Patients Older than 65 Years Undergoing Craniotomy for Acute Traumatic Subdural Hematoma. Taussky, et al WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.10.030

• Aneurysmal acute subdural hemorrhage: Prognostic factors associated with treatment. Kulwin et al. Journal of Clinical Neuroscience 21 (2014) 1333–1336

• The current role of decompressive craniectomy in the management of neurological emergencies. Honeybul. Brain Inj, 2013; 27(9): 979–991

• Extradural haematoma—To evacuate or not? Revisiting treatment guidelines. Zakaria et al. Clinical Neurology and Neurosurgery 115 (2013) 1201–1205

• Glasgow Coma Scale on admission is correlated with postoperative Glasgow Outcome Scale in chronic subdural hematoma. Amirjamshidi et al. Journal of Clinical Neuroscience 14 (2007) 1240–1241

• Advances in the management of intracerebral hemorrhage. Kuramatsu et al. J Neural Transm (2013) 120:S35–S41

• Neuroimaging in Intracerebral Hemorrhage. Macellari et al. Stroke. 2014;45:903-908.)

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• Outcome of acute and chronic subdural hematomas in patient 90 years and older. Stippler et al, 3.cns.org/dp/2012CNS/419.pdf

• Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience. Taussky et al, SWISS MED WKLY 20 08;138(19–20):281–285

• Subarachnoid Haemorrhage from Intracranial Aneurysms during Pregnancy and the Peurperium. Kataoka et al, Neurol Med Chir (Tokyo) 53,549-554. 2013

• Surgery for Intracerebral Hemorrhage Moving Forward or Making Circles? Flaherty. Stroke. 2013;44:2953-2954.

• Traumatic brain injury: intensive care management. Helmy et al. Br J Anaesth 2007; 99: 32–42

• Chronic Subdural Hematoma in Patients Over 90 Years Old in a Super-Aged Society. Tabuchi. J Clin Med Res. 2014;6(5):379-383

• Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Dankbaar et al. Critical Care 2010, 14:R23

• Long-term prognosis after intracerebral haemorrhage: systematic review and meta-analysis. Poon MTC, et al. J Neurol Neurosurg Psychiatry 2014;85:660–667

• New Developments in the Treatment of Intracerebral Hemorrhage. Gomes. Neurol Clin 31 (2013) 721–735

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