Hemorrhagic stroke is divided into spontaneous ICH and SAH
- hemorrhagic stroke has markedly worse outcomes than ischemic stroke
- 2 types of hemorrhagic stroke -> 1) spontaneous ICH and 2) aneurysmal SAH are the two common archetypes
- most CVAs are ischemic (80%); the remaining minority (20%) are hemorrhagic
- median 30d mortality is 40%
Associations with a poor prognosis
- DM
- male gender
- advanced age
- posterior fossa location
Most common sites for hypertensive bleeds
- deep perforator arteries in:
- pons
- midbrain
- thalamus
- basal ganglia
- deep cerebellar nuclei
- the second most common location for ICH:
- lobar region (45% of ICH) <- this location is more common w/ cerebral amyloid angiopathy
- less common location:
- posterior fossa (10% of ICH) <- this is associated w/ worst prognosis
CAUSES OF ICH
Aneurysms
- most likely to rupture into the subarachnoid space, but they can cause intraparenchymal hemorrhage
AVMs
- though they’re typically asymptomatic, these present more commonly w/ ICH
- these can be anywhere in the cerebrum, brainstem or cerebellum
Brain tumor
- rare cause of ICH accounting for ~5% of all cases
- commonly, they’re GBMs or oligodendrogliomas or they’re mets
- brain mets are commonly from lung cancers (as there’s high prevalence of lung cancer)
Uncommon causes of secondary ICH
- vasculitis
- sinus venous thrombosis
- carotid endarterectomy
- Moyamoya disease
- drug use
WORKUP/TREATMENT
ABC/2 formula
- A is greatest hemorrhage diameter; B is largest perpendicular to A; and C is the product of number of CT slices and the slice thickness
- gives ICH volume
- “spot sign” on CT angio is the extravasation of contrast which portends hematoma expansion
ICH score for 30d mortality and 12mo functional outcome
- GCS -> 1 point for 5-12
- age -> 1 point for > 80 y
- ICH vol -> 1 point for > 30 cc
- intraventricular spread -> 1 point for yes
- infratentorail origin -> 1 point for yes
*add the points up -> ~10%, ~20%, ~70%, and ~90% 30d mortality with point sum totals (1, 2, 3, and 4)
General ICP guidelines -> appear to have pretty much stayed the same from Morgenstern Stroke 2010 guidelines up to the more recent Hemphill Stroke 2015 guidelines
- there’s a paucity of studies on ICP-guided therapy for ICH -> they took a lot of the guidelines from the TBI literature
- first off, you decide if you need to insert one based upon the risk for hydrocephalus or the perceived need to drain CSF -> generally, place ICP monitor for GCS 3-8
- maintain CPP 50-70 mmHg with an ICP < 20 mmHg
- so, MAP goals generally 80-90 mmHg (b/c you’re assuming ICP 20-30 mmHg)
Blood pressure mgmt
- BP is usually elevated in the ICH pts
- In general, targeting a MAP of 110 mm Hg or BP 160/90 should be the goal
- also, if ICP monitoring available, target CPP of 50-70 mm Hg
- if ICP monitoring is not available, target MAP of 80-90 mm Hg b/c you’re assuming ICP is 20-30 mm Hg
- avoid nipride and nitroglycerin 2/2 tendency to increase ICP, lowering cerebral blood flow
- use cardene or labetalol or hydralazine or ACEi
INTERACT 2 trial
- 2,839 pts RCT to either rapid BP lowering w/ target SBP 140 mm Hg vs. target SBP 180 mm Hg
- there was a non-statistically significant benefit to the aggressive BP lowering <- however, this was not statistically significant
ATACH 2 trial
- Open label RCT with intervention of targeting lower BP in ICH (targeted SBP 110-139 mm Hg) throughout the first 24hr after randomization
- no difference in primary outcome of mRS 4 to 6 at three months out
Correction of coagulopathy
- vit K antagonists -> lack of consensus on how to best replace vit K-dependent factors
- 5-10 mg vit K IV, FFP, and PCC
- PCC may have fewer complications than PCC
- recombinant factor VII is not recommended as it will correct the INR, but not correct the other factors
- NOACs
