ARBO 2015 – Hemorrhagic Stroke -> Aneurysmal SAH and Spontaneous ICH

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