1、Intracranial Hemorrhage Marc Dorfman, MD, FACEP, MACPEM Residency Program Director Resurrection Medical CenterChicago, ILMarc Dorfman, MD, FACEP, MACPCase Presentation57 year old femaleSudden onset, severe headacheTook ASA for reliefSlurred speechCollapsedPhysical ExamT 99.4 P52 BP 195/99 RR13Pupils

2、-2 mm reactiveNeck-no JVD, bruitsCV-bradycardia, no murmurAbd-bs+, soft , nt/ndSkin-warm and dryNeurological ExamNeurological exam:no gag reflex, withdraws to pain, +4 DTR GCSEyes-1Verbal-1Motor-4NIH Stroke ScaleNIH Stroke ScaleNIHSS ScoreStroke scale 25CT ScanNY TimesKey Clinical QuestionsWhat are

3、the most common etiologies and locations of ICH?What are the goals of BP management?What are the optimal strategies for managing ICP?What other treatment modalities are available to the ED physcian?Key Clinical QuestionsWhich ICH patient require surgery?How does hemorrhage volume change over time? D

4、oes hemorrhage volume growth affect mortality?What are the new therapies being tested for this disease process?Intracranial HemorrhageEpidemiologyEtiologyDiagnosisTreatmentBP managementNeurosurgical indicationsNew treatment modalitiesICH Epidemiology30 day mortality: 35-52%50% of these in first 48 h

5、oursOne-fifth of survivors are independent at 6 months7000 operations annually in USA to remove blood ICH TypesEpiduralSubduralSubarachnoidIntraparencymalIntraventricularCerebellarHypertensive ICHHypertensionEssentialEclampsiaSympathomimeticsCocaineAmphetaminesPhenylpropanolamineHypertensive ICHBasa

6、l ganglia (50%)Contralateral hemiparesis, sensory loss, conjugate gazeLobar regions (20-50%)Contralateral hemiparesis or sensory loss, aphasia, neglect, or confusionThalamus (10-15%)Contralateral hemiparesis, sensory loss, gaze paresisPons (5-12%)Quadriparesis, facial weakness, decreased level consc

7、iousnessCerebellum (1-5%)Ataxia, miosis, gaze paresisOther ICH EtiologiesAmyloidTraumaVascular malformation-Avm, cavernoushemangiomasAneurysmTumorCoagulopathyVasculitisICH PresentationHypertension (90%)Altered mental status (50%)Headache (40%) Seizures (6-7%)ICH DiagnosisCT scanCT scan is the most e

8、ffective tool in the EDCT scan is excellent for imaging bloodICH Rx Key ConceptsTwo key concepts:Intracranial pressureElevated when ICP 20 mm HgCerebral perfusion pressureCPP=MAP-ICPMust maintain ICP 70 mm HgExample: MAP = 100, ICP = 20CPP in above example = 80 mmHg Increased ICP TreatmentIntracrani

9、al Pressure (ICP): considered a major contributor to mortality when elevatedControlling ICP is considered essentialOsmotherapyHyperventilationBarbiturate comaClinical Case: ED RxPatient starts to vomitB/P 266/122RSILidocaine 100 mgsEtomadate 20 mgsSuccinylCholine 100 mgsMannitol 150 ccsElevate Head

10、of Bed Hyperventilation to pCO25-30Clinical Case: ED RxParalytics-Pancuronium 7 mgBP management-NiprideSteroids-Decadron 10 mgsOsmotherapyOsmotherapy-MannitolReduces cerebral edema by decreasing cerebral fluid volumeRebound effect-use less than 5 days20% solution0.5-1.0 mg/kg maintain serum osmolari

11、ty 310-320 mOsm/LHOB ElevationElevate head of bed-decrease ICPMechanical-helps drain blood by gravityDoes not allow blood to pool in cranium, which may occur if patient is left laying flatEndotracheal IntubationIntubation-not required, but airway protection and adequate ventilation are necessaryRely

12、 on clinical suspicion, not GCSHyperventilation decreases ICP pCO2 should be kept around 30-35Beneficial effect of sustained hyperventilation is not provenParalyticsRecommended in order to prevent increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT,

13、 all of which may cause ICP spikesICP spikes associated with poorer outcome, especially in setting of elevated ICPICP MonitorsAHA recommends ICP monitors in patients with a GCS less than 9 and all patients whose condition is thought to be deteriorating due to elevated ICPBP ManagementLower blood pre

14、ssure to decrease risk of ongoing bleeding from ruptured small arteriesOveraggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injuryEspecially true with elevated ICPBP ManagementAHA recommends blood pressure be maintained below a mean arterial pressure o

15、f 130 mm Hg in persons with a history of hypertensionIf there is an ICP monitor:ICP should be kept 70 mm HgBP ManagementAvoid hypotensionIf systolic BP drops to less than 90 mmHg, consider judicious fluid boluses and/or start pressorsBP ManagementLabetalol20 mg IV, followed by 40 80 mg IV q10 minTit

16、rate to BP or max 300 mgs adminNipride0.5-1.0 mics/kg/minTheoretically can increase cerebral blood flow and thereby intracranial pressureBP ManagementTreatment should be started within 6 hours of symptom onsetA Prospective Multicenter Study to Evaluate the Feasibility and Safety of Aggressive Antihy

17、pertensive Treatment in Patients with Acute Intracerebral HemorrhageJournal of Intensive Care Medicine, Vol 20, No 1Burke, Dorfman-not yet publishedFever ManagementElevated temperatures can increase the degree of ischemic injury. Etiologies include infection, neuronal injury, SIRSStudies have demons

18、trated increased morbidity and mortality in patients with sustained temperature elevation. Treat temperture 38.5 CAcetaminophen or a cooling blanket best options. Seizure TherapyNeuronal injury may lead to seizuresNonconvulsive seizures may contribute to coma in up to 10% of neurocritical patientsCo

19、nsider prophylactic antiepileptic therapy in setting of ICHLobar hemorrhage-35% seizure rateFosphenytoin or phenytoinMedical TherapyEuvolemiaIsotonic crystalloid solutionsElectrolyte abnormalitiesCorrect deficitsAcid/base disordersCorrect them if presentSteroids-no benefitBlood ClotICH Hemorrhage Gr

20、owthUntil recently, bleeding in patients with ICH was thought to be completed within minutes of onsetSeveral small studies describe a few patients who had an increase in the volume of parenchymal hemorrhage on repeated CT scansICH Hemorrhage VolumeOld concept-Hemorrhage static process; bleeding comp

21、lete in a minutesNew concept-Hemorrhage is dynamic; process continues for several hoursICH Hemorrhage GrowthEarly Hemorrhage Growth in Patients With Intracerbral HemorrhageBrott, Broderick, KothariStroke Vol 28, 1 January 1998ICH Growth: Study PurposeProspectively determine how frequently early grow

22、th of intracerebral hemorrhage occurs and whether this early growth is related to neurological deteriorationICH Growth Study Design102 patientsCT scan 3 hours and 24 hours38% patients with 33% growth in volume of parenchymal hemorrhageICH Growth: Conclusions Substantial early hemorrhage growth in pa

23、tients with with intracerebral hemorrhage is common and is associated with neurological deterioration.Randomized treatment trials are needed to determine whether this ongoing bleeding and frequent neurological deterioration can be improvedICH Factor VIIa StudySafety and Feasibility of Recombinant Fa

24、ctor VIIa for Acute Intracerebral HemorrhageMayer, Nikolai, BrunStroke, Jan 2005, 36(1) p74-9ICH Factor VIIa Study PurposeFactor VIIa-promotes clotting-know to do so in hemophiliacsActivated factor VII promotes hemostasis at sites of vascualr injury and may minimize hematoma grwoth in ICHICH Factor

25、VIIa Study Design48 subjectsRandomized double blind placebo controlledEscalating doses of factor VIIEndpoint-frequency of adverse eventsICH Factor VIIa Study ConclusionPhase II trialNo major safety concernsLarger study needed to determine if factor VII can safely and effectively limit ICH growthED P

26、atient ManagementNeurosurgery consultedEVD placed in the EDPatient taken to the OR for evacuation of hematomaBP-119/79 P-92 RR-12Patient OutcomeNext day: brain flow studiesPatient declared brain deadPatient extubatedICH Surgical IndicationsCerebellar hemorrhage 3 cm who are deteriorating or with brain stem compression and hydrocephalus from ventricular obstructionVascular malformation if lesion is surgically accessible and patient has chance for good ou