Epidemiology and Pathophysiology of Intracerebral Hemorrhage

1
Epidemiology and Pathophysiology of
Intracerebral Hemorrhage
Edward C. Jauch, MD MS FACEP
1
2
Edward C. Jauch, MD MS FACEPAssistant
ProfessorAssociate Director of
ResearchDepartment of Emergency
MedicineUniversity of Cincinnati College of
MedicineFaculty, Greater Cincinnati / Northern
Kentucky Stroke Team
2
3
Global Objectives

• Review epidemiology of ICH
• Understand pathophysiology of ICH
• Discuss lessons from acute ischemic stroke
• Improve Emergency Medicine practice

4
A Clinical Case
5
Patient Initial Clinical History

• 57 yo male with sudden onset headache and left
  sided weakness
• Family calls 911
• EMS transport to OLFH Hospital
• Enroute patients symptoms progress to full
  hemiplegia
• Initial VS 210 / 120 mmHg, HR 110, R 24

6
Patient ED Presentation

• PMHX HTN for 10 years, hyperlipidemia
• SHX Smoking 30 years
• Meds ACE inhibitor, ASA
• ROS No recent illness or injuries, no new
  medications

7
Patient ED Presentation

• Physical examination
• VS - 220 / 140 mmHg, HR 110, RR 22, T 98.6oC
• Uncomfortable WM, arouses to voice
• HEENT/CV/Lungs/Abd - WNL
• Neuro
• LOC mildly depressed
• CN with L facial droop and partial gaze palsy,
  VFI
• Motor with dense L hemiplegia
• Sensory with mild L sensory loss
• Speech slurred but no significant aphasia
• NIHSS 12

8
Key Questions

• What is your differential diagnosis?
• What are the most common ICH etiologies?
• What is the pathophysiology of ICH?
• What guidelines exist that govern the acute care
  of ICH patients?
• What can be learned regarding ICH management from
  acute ischemic stroke?
• How can the emergent care of ICH patients be
  enhanced?

9
Patient ED Presentation

• Initial noncontrast CT scan
• Labs
• CBC, chem 7 WNL
• PT, PTT WNL
• ECG LVH with strain

10
Stroke Subtypes
Up to 65,000 ICH per year in U.S.
(NINCDS Stroke Data Bank Foulkes, Stroke, 1988)
11
ICH Classifications

• Primary
• Hypertensive arteriopathies
• Cerebral amyloid angiopathies
• Secondary
• Neoplasms
• Structural lesions
• Anticoagulants or thrombolytic agents
• Drugs (cocaine, ephedra, etc)
• Traumatic brain injury

12
Location

• Lobar
• Associated with amyloid angiopathy
• Nonlobar
• Associated with hypertension
• Cerebellar
• Intraventricular

13
Lobar Hemorrhage

• Secondary to cerebral amyloid angiopathy
• Beta-amyloid deposition in vessels of cortex and
  leptomeninges
• Associated with aging
• Lobar hemorrhage in young due to AVM, cavernous
  hemangioma

14
Non-lobar Hemorrhage

• Non-lobar or hypertensive hemorrhage
• Associated with hypertensive arteriolosclerosis
• Location
• putamen, pons, thalamus, cerebellum
• Mortality
• 50 30 day mortality
• Exam
• sudden HA with focal findings on exam

15
Risk Factors

• Age
• Gender (men gt women)
• Race (blacks gt whites)
• Prior stroke
• Hypertension
• Anticoagulant / thrombolytics
• Alcohol / cocaine

19 yo with ephedra induced ICH
16
Less Common Risk Factors

• Vascular malformations
• Arteriovenous malformations (AVM)
• Cavernous angiomas
• Intracranial aneurysms
• Infections
• Cerebral vasculitis
• Mycotic aneurysms
• Cerebral venous thrombosis

17
ICH Rate by Age
Rate per 100,000 / year
Age (years)
18
Systolic Blood Pressure Incidence
Incidence Rate/100,000
Systolic Blood Pressure (mmHg)
19
Ethnicity of ICH Risk

• Age and sex adjusted rate
• U.S. 15 per 100,000
• World wide 10-20 per 100,000
• Higher in African American and Japanese
• Rates 13.5 per 100,000 Caucasian 38 per
  100,000 AA 55 per 100,000 Japanese

20
Anticoagulation and Thrombolytic Related
Hemorrhage

• Warfarin anticoagulation
• 6-11 fold increased risk of ICH
• Higher levels with increased risk
• Most occur in therapeutic range
• Thrombolysis and Symptomatic ICH
• 6.4 in thrombolysis treatment group
• tPA related hemorrhages typically lobar
• 20 occur outside area of infarct
• 0.6 in placebo group

21
Mortality and Morbidity

• Estimated lifetime cost 123,565
• Of the 37,000-65,000 ICH per year
• 35-52 were dead at 1 month
• 50 of deaths occurred within 48 hours
• 10 independent at 30 days
• 20 independent at 6 months

22
30 Day Outcome of ICH
No. cases
Modified Oxford Handicap Scale
23
Clinical Presentation

• Symptoms and signs
• 82 change in mental status
• gt75 hemiparesis/plegia
• 63 headache
• 22 vomiting
• 2/3 progression of symptoms, 1/3 maximal at onset

24
Clinical Presentation by Location

• Lobar
• Headache (headache location related to ICH site)
• Motor, sensory deficit, or VF deficits (not all)
• Deep
• Unilateral motor, sensory, VF loss
• Aphasia (D) or neglect (ND)
• Cerebellum
• Nausea, vomiting, ataxia, coma
• Pontine
• Coma, quadriplegia, pinpoint pupils

25
ICH Progression

• Symptoms often progress, associated with ICH
  growth
• 26 with 33 or greater growth in 1 hour
• 12 with 33 or greater growth 1-20 hours
• This gives us a window of therapeutic opportunity

26
Prognostic Information

• Volume of hemorrhage
• Clinical presentation
• Intraventricular extension

(Kothari, Stroke)
27
Hematoma Volume Calculation

• Formula for volume of an ellipsoid
• 4/3? (A/2)(B/2)(C/2)
• Simplified ABC/2

28
Prognosis

• Worse
• Volume gt 60 cm3 and GCS lt 9
• 91 dead at 30 days
• Patients with volume over 30 cm3 only 1 / 71
  independent at 30 days
• Intraventricular extension
• Better
• Volume lt 30 cm3 and GCS 9 or higher
• 19 dead at 30 days

(Broderick, Stroke)
29
Pathophysiology

• Initial hemorrhage into surrounding tissues
  causes
• Cytotoxic and vasogenic edema formation in the
  perihematomal parenchyma
• Neurotoxicity from released serum proteins
• Elevated intracranial pressure due to
• Hematoma mass effect
• Perihematomal edema
• Intraventricular extension and hydrocephalus
• Results in decreased perfusion

30
Current Recommendations for Management of
Intracerebral Hemorrhage

• Emergency Medicine representation
• New guidelines due 2005

Edward C. Jauch, MD MS FACEP
(Broderick, Stroke 1999)
30
31
Emergent Evaluation

• Baseline labs
• CBC, coags, electrolytes
• Neuroimaging
• CT remains gold standard
• Identify ICH
• Identify complications (hydrocephalus,
  herniation)
• MRI / MRA
• Useful to evaluate for structural abnormalities
• AVM, aneurysms
• Angiography
• Rarely emergently indicated
• Identify vascular issues preoperatively in occult
  ICH

32
Medical Management

• ABCs
• Blood pressure control
• ICP management
• Hyperventilation
• Osmotherapy
• No role for glycerol, corticosteroids,
  hemodilution
• Other
• Prevention of hyperthermia
• Fluid management (CVP at 5-12 mm Hg)
• Modifications for age, comorbidities, size,
  severity, location
• Seizure control
• Find somebody to take the patient

33
Blood Pressure Management

• No definitive data (yet)
• Hypertension very common
• MAP gt 140 in 34, gt 120 in 78
• Many return to baseline over first 24 hours

Prospective Retrospective Case Series Results
Meyer et al. 1962 Lower BP good
Dandapani et al. 1995 Lower BP good
Qureshi et al. 1999 Lower BP bad
Brott T et al 1995 Hematoma enlargement not associated with degree of HTN
 
(Dr. Aninda Acharya, St.Louis University,
Internet Stroke Center)
34
Blood Pressure Management
Edward C. Jauch, MD MS FACEP
(Broderick, Stroke 1999)
34
35
Management of Increased ICP

• Definition
• ICP gt 20 mm Hg for gt 5 mins
• Treatment goal
• ICP lt 20 mm Hg
• CPP gt 70 mm Hg
• Recommendations
• ICP monitoring with GCS lt 9
• Management
• Osmotherapy
• Hyperventilation
• Ventricular drainage

 
36
Management of ICP
Edward C. Jauch, MD MS FACEP
(Broderick, Stroke 1999)
36
37
Seizure Therapy

• 25 will have seizure
• Much more common if lobar
• Most in first 72 hours
• Phenytoin is drug of choice
• Does not convey life long epilepsy

38
What can be Fixed?

• Stop the bleeding
• Until now no option
• Remove the blood
• Multiple trials without clear impact
• Reduce the edema
• No treatment yet

39
Surgical Treatment

• Direct evacuation, endoscopic, stereotactic

40
Surgical Treatment Recommendations

• 7000 procedures a year in U.S. despite lack of
  data
• Largest surgical trial negative (in press)
• MISTIE trial of stereotactic evacuation with tPA
• (3/05) Surgery in 24 hrs, stable clot for 6 hrs

(Broderick, Stroke 1999)
40
41
The Potential Future With Novo 7What Can We
Learn From Acute Ischemic Stroke?
41
42
Time Will Always Mean Brain!
(Lancet 2004 363 76874)
43
Same Chain No Weak Links

• Development Protocol and pathway development
• Detection Early recognition
• Dispatch Early EMS activation
• Delivery Transport management
• Door ED triage
• Data ED evaluation management
• Decision Neurology input, therapy selection
• Drug Thrombolytic future agents
• Disposition Admission or transfer

43
44
Emergent Triage and ED EvaluationMust be a
Priority
45
NINDS Recs Same for ICH

• Door-to-MD 10 minutes
• Door-to-Stroke 15 minutes
• Team notification
• Door-to-CT scan 25 minutes
• Door-to-Drug 60 minutes
  
• (80 compliance)
• Door-to-Admission 3 hours

(NINDS Stroke Symposium 2003)
46
There Will Be Major Barriers

• EM education of disease and treatment
• Timely radiology involvement
• Access to neurologic expertise
• Neurology does not admit ICH
• Neurosurgeons wont rush in
• EM will be point person like tPA
• Post treatment management
• ICU beds
• Complications likely to occur early
• Cost
• Whose cost center
• Drip and ship model

47
Who Cares for Patients with ICH?

• Shortage of neurosurgeons
• Shortage of neurocritical care
• Neurologists not experienced with ICH
• Emergency Medicine primarily focused on
  stabilization
• Example Cincinnati
• 30 neurosurgical shortage
• Nonoperative ICH to neurology
• Only 4 of 15 hospitals with neurosurgery coverage
  
• Only 1 level 1 trauma largely due to neurosurgery

48
Potential SolutionUtilize Primary Stroke Centers

• Patient care areas
• Acute stroke teams
• Written care protocols
• EMS participation
• Emergency Department participation
• Stroke unit
• Neurosurgical services

• Support services
• Organizational support
• Stroke center director
• Neuroimaging
• Laboratory
• Outcome quality measures
• CME

• Secondary stroke center likely required for most
  ICH

(Brain Attack Coalition, JAMA 2000)
49
ED Treatment and Patient Outcome
50
Questions?? www.ferne.orgferne_at_ferne.orgEdwar
d Jauch, MD, MSjauchec_at_ucmail.uc.edu(513)
558-0474
ferne_acep_2005_jauch_ich_epipath_cd 12/26/2013
61727 AM