UNDER PRESSURE: Intracerebral Hemorrhage Rhonda Finnie, DNP, APRN, AGACNP-BC, ANVP-BC Baptist Health Neurosurgery Arkansas – Baptist Health Neurology Stroke Symposium October 26, 2017

I have no disclosures…

Identify risk factors, etiology, and clinical features associated with intracerebral hemorrhage Describe evidenced-based management and treatment options for these patients

What I am NOT talking about….

Mortality and Disability Overall, 40% mortality at 1 month and 54% at one year Only 12-40% are functionally independent long term 2010 – 62.8 million lost DALYs with ICH compared to 39.4 million in ischemic stroke

ICH more common depending on …. Ethnicity – Asians Age - Older age Gender - Male Race in the US – 48.9 vs 26.6 per 100,000

Risk Factors HTN Excessive ETOH use Smoking Age Ethnicity/Race Medications Sympathomimetics

INTERSTROKE study International case-control study HTN, smoking, waist-hip ratio, diet and excessive ETOH intake Accounted for 88.1% of the population attributable risk!

Medications

Medications

Other Causes AVM, aneurysms, and other vascular malformations (venous and cavernous angiomas) CVT Intracranial neoplasm Amyloid angiopathy Moya Moya

Monro-Kellie Doctrine

Mechanisms of Injury Primary Secondary Brain compression Vasogenic edema Blood toxicity Activation of multiple immune pathways

What do these patients look like?

The Workup… CT head – no contrast CTA head/neck – suspect vascular etiology Careful interpreting noncon CT head after CTA or other dye study MRI brain – with gado if looking for neoplasm MRA/MRV - if allergic to CT dye or if looking at venous outflow Cerebral angiography

Location! Location! Location! Basal ganglia Thalamus Pons/brainstem Cerebellum Lobar

ICH score – what does it tell you?? ICH scores with corresponding mortality risk Score Good Outcome at 30 days In hospital mortality 30 day mortality 5 83% 12% 17% 6 76% 6% 8% 7 60% 13% 20% 8 27% 32% 43% 9 18% 57% 71% 10 4% 87% 11 0% 97% 100% 12 13

In a nutshell… Airway BP Coagulopathy Surgery

What to do????? Control BP!!!! Guidelines – reduction of SBP to 140 is safe Anderson/Qureshi studies – Interact 2 and ATACH 2 Not clear if SBP > 220 Use labetalol and/or nicardipine drip to titrate blood pressure Between 15-23% of patients > hematoma expansion in first few hours A word about penumbra

VKA and NOACs Correct coagulopathy APT DTIs Xa drugs INR < 1.4 Vitamin K/FFP PCC – 4 factor – Kcentra *rFactor VII - FAST trial APT DDAVP Decadron Platelets if surgery an option DTIs Pradaxa Idarucizumab Xa drugs PCC - KCentra Andexanet alfa on the horizon hopefully

Order Sets

TXA

What do we do?? EBP nursing care Watch for neuro decline Type and cross with your labs!!! HOB > 30 Head midline Prevent vagal maneuvers Control SBP Treat hyperglycemia Treat hyperthermia Seizure prophylaxis DVT prophylaxis Typically, do not make patients DNR within the first 48 hours

Cerebral Edema: Sodium and CO2 Use the ventilator to manage CO2 Get the sodium up Mannitol/3% or even 23.4% (requires central line) for herniation

Surgery anyone???? EVD Craniotomy CLEAR III trial – no outcome benefit with vent use of tPA Craniotomy Depends on etiology **Depends on AC/APT status Depends on timing Depends on location STICH II – no overall favorable outcome MISTIE II – MIS techniques MISTIE III – underway Cerebellar ICH

Subarachnoid Hemorrhage Usually due to aneurysm rupture Can be perimesencephalic SAH Coil/Clip NIMOTOP/NIMODIPINE Strict BP control Hydrocephalus Vasospasm Sodium Urine output

Hemorrhagic Transformation HI 1/2 – PH 1/2 > 50% have some hemorrhage 0.6%-3% >> untreated patients 6% in treated patients Risk Factors Older age larger stroke size cardioembolic stroke etiology1 anticoagulant use fever hyperglycemia low serum cholesterol Acutely elevated systolic blood pressure thrombolytic therapy/recanalization Treatment

References An, S.J., Kim, T.J., and Yoon, B.W. (2017). Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: An update. Journal of Stroke, Jan 19(1), 3-10 Dastur, C.K. and Yu, W. (2017). Current management of spontaneous intracerebral hemorrhage. Stroke and Vascular Neurology, Retrieved from www.svn.bmj.com Frontera, J, et al (2016). Guideline for reversal of antithrombotics in intracranial hemorrhage: A statement for healthcare professionals from the NeuroCritical Care Society and the Society of Critical Care Medicine. Neurocritical Care (24), 6-46. Glick, J. & Gaillard, F. (2017). Haemorrhagic transformation of ischaemic infarct. Retrieved from www.radiopaedia.org Hemphill, J.C., et al. (2015) Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. Published online May 28, 2015. Retrieved from www.stroke.ahajournals.org Jones, J. (2017). Intracerebral haemorrhage. Retrieved from www.radiopaedia.org.