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Hemorrhagic Stroke

Kyle Schmidt, MD PGY-7UNMC Department of Neurosurgery

September 17, 2019

Methodist Hospital

No conflicts of interest.

Objectives

1) Review hemorrhagic stroke pathophysiology

2) Discuss hemorrhagic stroke presentation

3) Review management of hemorrhagic stroke

Quick Review Of Anatomy

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Quick Review Of Anatomy

https://sites.google.com/site/postgraduatetraining/anatomy/under-spin/slide-2

RIGHT

Stroke

● Broadly defined (AHA/ASA 2013)○ CNS Infarction of the brain, spinal cord, &/or retina due to ischemia

with symptoms lasting >24 hours ○ Also includes: ischemic stroke, silent CNS infarction, intracerebral

hemorrhage, silent cerebral hemorrhage, subarachnoid hemorrhage, cerebral venous thrombosis, not otherwise specified

Stroke = CVA = “Cerebrovascular accident”

Questions:1. Have you had a patient state, “I haven’t had a

major stroke but I’ve had mini-strokes”?

2. What is a mini-stroke?A. TIA (stroke-symptoms <24 hrs)B. Imaging findings of chronic small vessel

ischemic diseaseC. An asymptomatic strokeD. Whatever the patient wants it to beE. Any of the above

Questions:

STROKE● Broadly defined (AHA/ASA 2013)

○ CNS Infarction of the brain, spinal cord, &/or retina due to ischemia with symptoms lasting >24 hours

○ Also includes: ischemic stroke, silent CNS infarction, intracerebral hemorrhage, silent cerebral hemorrhage, subarachnoid hemorrhage, cerebral venous thrombosis, not otherwise specified

1. Have you had a patient state, “I haven’t had a major stroke but I’ve had mini-strokes”?

2. What is a mini-stroke?A. TIA (stroke-symptoms <24 hrs)B. Imaging findings of chronic small vessel

ischemic diseaseC. An asymptomatic strokeD. Whatever the patient wants it to beE. Any of the above

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Stroke● Two groups:

○ ISCHEMIC → 80-85%○ HEMORRHAGIC → 15-20%

■ Intraparenchymal/intracerebral hemorrhage, subarachnoid hemorrhage

● Ischemic may progress to hemorrhagic transformation (over days)

PATHOPHYSIOLOGY GUIDES MANAGEMENT• Not enough flow? Ischemic• Too much abnormal flow? Hemorrhagic

Ischemic StrokeA few words about ischemic stroke

Ischemic StrokeWhich one of these patient’s is having an ischemic stroke?

Ischemic vs Hemorrhagic

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Ischemic StrokeWhich one of these patient’s is having an ischemic stroke?

Acute Ischemic Stroke

Large Vessel Occlusion

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Intracranial Thrombectomy

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Intracranial Thrombectomy Malignant Cerebral Edema

Decompressive CraniectomyHemorrhagic Stroke

• Pathophysiology difficult to specifically define due to multiple etiologies of hemorrhagic stroke

• In general, typically due to bleeding from small arteries in or around the brain

• Major healthcare burden• 2002 67,000 ICH (intracerebral hemorrhage) cases

• 20% expected to be independent at 6 months

• ≈44% 30-day mortality for all-comers

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Hemorrhagic stroke

• Multiple underlying conditions result in hemorrhagic stroke

Hemorrhagic Stroke

• Presentation: Headache, seizure, neuro deficits, altered mental status

• Approx 2/3 of patients with intraparenchymal hemorrhage have chronic hypertension

Basal Ganglia Hemorrhage (“Hypertensive hemorrhage”)

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Hemorrhagic Stroke

• Treatment: Typically blood pressure control and supportive cares

• Possible clot evacuation

Basal ganglia hemorrhage

Hemorrhagic Stroke

• Cerebral amyloidosis beta amyloid protein deposits in small meningeal and cortical vessels• Lobar hemorrhages in the elderly• ≈ 10% of intraparenchymal hemorrhages

Amyloid angiopathy

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Hemorrhagic Stroke

• Presentation: Headache, seizure, neuro deficits, altered mental status

• Treatment: Supportive cares

Amyloid angiopathy

Hemorrhagic Stroke

• Presentation: “Worst headache of your life”, loss of consciousness, sudden death, 10% intra-coital

• Initial Management: Blood pressure control

Subarachnoid hemorrhage (SAH) due to aneurysm rupture

Aneurysmal SAH

• Treatment: Procedural EVD (if hydrocephalus present)• Secure aneurysm coiling or clipping

• Ideally treat shortly after presentation to prevent re-rupture• ≈20% re-rupture at 2 weeks, 50% at 6 weeks if unsecured

Subarachnoid hemorrhage (SAH) due to aneurysm rupture

https://www.researchgate.net/profile/WJ_Niessen/publication/229018689/figure/fig1/AS:3007357

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Aneurysm Clipping

• Craniotomy with aneurysm clipping

Subarachnoid hemorrhage (SAH) due to aneurysm rupture

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Aneurysm Coiling

• Endovascular therapy

Subarachnoid hemorrhage (SAH) due to aneurysm rupture

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Aneurysm Coiling

• Endovascular therapy

Subarachnoid hemorrhage (SAH) due to aneurysm rupture

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Hemorrhagic StrokeAVM (arteriovenous malformation)

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https://www.mayoclinic.org/-/media/kcms/gbs/patient-

consumer/images/2014/03/20/15/47/mcdc7_arteriovenous_malformation.gif

Hemorrhagic StrokeAVM (arteriovenous malformation) rupture

• Presentation: • Non-ruptured seizure, headache, focal neurologic deficit,

incidental• Ruptured: Headache, seizure, neurologic deficit

• Initial management: Blood pressure control

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AVM

• Treatment: Observation, radiation, embolization, surgical resection• Decompression if significant mass effect

AVM (arteriovenous malformation) rupture

AVM Management

AVM Management Hemorrhagic Stroke

• Presentation: Headache, neurologic deficit (acute or chronic), seizure

• Initial management: Blood pressure control

• Treatment: Depends on pathology

Hemorrhagic Tumor

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Most Common Culprit?Hypertensive hemorrhage

Hypertensive Intracranial Hemorrhage (ICH)• Prospective data from late 1980s/early 1990s

• Risk factors: African American ethnicity, age, hypertension• SBP >160 or DBP >110 5.5x rate of ICH

• Small branches (50-200µm) off larger arteries• Develop microatheromas and lipohyalinosis

• Lead to alterations of structural components of vessel wall

Winn, H.R. (2011). Youman’s Neurological Surgery. Philadelphia. Elsevier Saunders.

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Initial Management of ICH

• Initial Evaluation and Management • ABCs!

• Maintain appropriate blood pressure• Assess for significant hypertension (expand hemorrhage) or

hypotension (decrease cerebral perfusion)

• >20% of patients experience a decrease in GCS of 2 or more points between EMS assessment and initial ED evaluation

• Additional15-23% have continued deterioration after hospital arrival

https://img.medscapestatic.com/pi/meds/ckb/40/23340.jpg

AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage, 2015

From an ER/ICU Standpoint• Initial evaluation of suspected stroke (once stabilized)

• Challenging as symptoms vary depending on location of hemorrhage• Syncopal event, focal deficit, headache, confusion

• Large overlap of symptoms between hemorrhagic and ischemic

• History and Physical• Symptom onset, anticoagulant or antiplatelet use, hypertension history,

medications, substance use• NIH Stroke Scale

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Common Clues to ICH Etiology• SBP >220, severe headache, emesis, decreased level of

consciousness, rapid symptom progression

• A few buzzwords/phrases

• “This is the worst headache of my life” or “thunderclap headache”• Subarachnoid hemorrhage (often aneurysmal)

• “He has high blood pressure and will not take his meds”• Hypertensive

• 85 yo “she has had a couple small bleeds over the years…”• Amyloid angiopathy

• “They have been doing cocaine again…”

Common Clues to ICH Etiology• SBP >220, severe headache, emesis, decreased level of

consciousness, rapid symptom progression

• A few buzzwords/phrases

• “This is the worst headache of my life” or “thunderclap headache”• Subarachnoid hemorrhage (often aneurysmal)

• “He has high blood pressure and will not take his meds”• Hypertensive

• 85 yo “she has had a couple small bleeds over the years…”• Amyloid angiopathy

• “They have been doing cocaine again…”

• STAT neuroimaging (typically CT)

Management of ICH Initial Management of ICH

• Initial Blood Pressure Control• If initial SBP 150-220, “probably safe” to acutely lower <140 (IIa, level B)

• Based on ATACH (Antihypertensive Treatment of Acute Cerebral Hemorrhage) and INTERACT1 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage)

• “High SBP is associated with greater hematoma expansion, neurological deterioration, and death and dependency after ICH.”

• Anti-coagulant agents: Need reversal

• Admission to ICU with “neuroscience nurse and physician expertise” lower mortality rate• May require transfer to another facility

28-38% of ICH on CT within 3 hours of event had expansion on follow-up imaging

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ICH and Blood Pressure• Extended period of blood pressure control

• SBP goal <140 or <180?

ICH and Blood Pressure• Blood Pressure Control

• INTERACT2 2839 patients, SBP 150-220 and w/in 6 hours of symptoms• One group: SBP target <140 for 7 days• Second group: SBP target <180 for 7 days• No significant difference in primary outcomes (death or major disability)• Secondary outcome (functional recovery): Group one (SBP <140) with

significantly better functional recovery

• No difference in primary outcomes if SBP <140 or <180

Why not use this?

• Intensively controlled group (SBP <140) mean SBP: 128

• Standard group (SBP goal <180) mean SBP: 141

• Kept at SBP goal for 24 hours only

• Also identified increased risk of renal problems in intensively controlled group

Surgical Management of ICHSurgical Treatment of ICH (STICH Trial, STICH II), among others, with unclear evidence

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Posterior fossa• Relatively confined area

• Important structures (brainstem)

Should this patient have surgery?

• 85 yo male• GCS 12 (6M 3E 3V)

Should this patient have surgery?

• Hospital day 6 CT• GCS 12 (6M 3E 3V)

Should this patient have surgery?

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Should this patient have surgery?

Prognosis

• Can we give a useful prognosis?

Prognosis Tool: ICH Score

https://www.mdcalc.com/intracerebral-

hemorrhage-ich-score

Prognosis Tool: ICH Score

https://www.mdcalc.com/intracerebral-hemorrhage-ich-score

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“She/he would only want to live with a good outcome…”

https://www.researchgate.net/profile/Canan_Gursoy3/publication/310754406/figure/tbl1/AS:674479411851267@1537819831538/Glasgow-outcome-scale-GOS.png

Glasgow Outcome Scale (GOS)

What does this mean?

In Closing

• Reviewed the various conditions resulting in hemorrhagic stroke

• Discussed management of various ICH conditions depends on pathology causing ICH

• Reviewed ICH prognosis and challenges with prognosis

Questions/Comments?

Thank you for your time!