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

2. I have no disclosures…

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

4. What I am NOT talking about….

6. 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

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

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

9. 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!

11. Medications

12. Medications

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

14. Monro-Kellie Doctrine

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

16. What do these patients look like?

17. 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

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

19. 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

20. In a nutshell…
Airway BP
Coagulopathy
Surgery

21. 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

22. 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

23. Order Sets

24. TXA

25. 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

26. 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

27. 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

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

29. 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

30. 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
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
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, Retrieved from
Jones, J. (2017). Intracerebral haemorrhage. Retrieved from