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Intracerebral Hemorrhage (ICH) PowerPoint Presentation

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Description : Check out this medical presentation on Antihypertensive, which is titled "Intracerebral Hemorrhage (ICH)", to know about predicting hematoma expansion, Preventing hematoma expansion (Blood pressure control, Reversing INR, Platelet transfusion, and Metabolic), and monitoring for complications of ICH (Seizures and Hydrocephalus).

Tags : Check out this medical presentation on Antihypertensive, which is titled "Intracerebral Hemorrhage (ICH)", to know about predicting hematoma expansion, Preventing hematoma expansion (Blood pressure control, Reversing INR, Platelet transfusion, and Metabolic), and monitoring for complications of ICH (Seizures and Hydrocephalus).

Published on : May 25, 2021 | Views : 4327 | Downloads : 7

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Slide 1-

Intracerebral Hemorrhage (ICH) Krishna Nalleballe MD
Slide 2-

Acute Management of ICH Predicting hematoma expansion Preventing hematoma expansion Blood pressure control Reversing INR Platelet transfusion? Metabolic Monitoring for complications of ICH Seizures Hydrocephalus
Slide 3-

24-48 12-24 0-3 6-12 3-6 hours from onset Stroke 1996;27:1783-87 Is it expanding?
Slide 4-

Spot sign Wada et al., 2007
Slide 5-

Select CT slice with largest ICH A = longest axis (cm) B = longest axis perpendicular to A (cm) C = number of slices x slice thickness (cm) A x B x C Calculating ICH volume 2
Slide 6-

Godoy, D. A. et al. Stroke 2006 Score 30-day mortality 0 0% 1 13 2 26 3 72 4 97 5, 6 100 ICH score
Slide 7-

Impact of intraventricular blood _____ ICH =80 cc, GCS 8 …….. ICH =80 cc, GCS >8 __ __ ICH =20 cc, GCS 8 ----- ICH =20 cc, GCS >8 Tuhrim et al. Crit Care Med 1999;27:617-21
Slide 8-

Preventing hematoma expansion Blood pressure control Reversing INR ? Platelet transfusion Metabolic
Slide 9-

Preventing Hematoma Expansion Blood Pressure Control
Slide 10-

Target blood pressure 140 systolic? INTERACT 2 trial Patients within 6 hours of onset of ICH Treatment arm: SBP <140 Control arm: SBP <180
Slide 11-

Systolic BP time trends 1 hour - Δ14 mmHg (P<0.0001) 6 hour - Δ14 mmHg (P<0.0001) Intensive group to target (<140mmHg) 462 (33%) at 1 hour 731 (53%) at 6 hours INTERACT 2: results
Slide 12-

INTERACT 2: results No difference between groups in death or major disability Intensive blood pressure lowering resulted in better functional outcomes at 90 days than standard therapy
Slide 13-

BP Control AHA Statement: For ICH patients presenting with SBP between 150-220 mm Hg and with out contraindication to acute BP treatment, lowering of SBP to 140 mm Hg is safe (class1; Level of Evidence A) and can be effective for improving functional out come (class 2a; Level of Evidence B) For ICH patients presenting with SBP>220 mm Hg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring (class 2a; Level of Evidence C)
Slide 14-

Preventing Hematoma Expansion Reversing Anticoagulation
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Reversing the INR No more fresh frozen plasma Choose prothrombin complex concentrate Kcentra Vitamin K dependent coagulation factors II, VII, IX, X and protein C+S Give vitamin K IV along with it
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Kcentra vs. FFP Patients with INR ≥ 2 requiring reversal of INR for an acute major bleeding event Primary endpoints: Hemostatic efficacy within 24 hours of the infusion (excellent, good, poor, none) INR half hour after the infusion
Slide 17-

Results Effective hemostasis in 72.4% of the 4-factor PCC group vs. 65.4% of the FFP group PCC non-inferior to FFP INR ≤ 1.3 at half an hour after the end of the infusion in 62.2% of the PCC group vs. 9.6% of the FFP group PCC superior to FFP
Slide 18-

Adverse events Kcentra ischemic stroke DVT FFP 2 MIs fluid overload respiratory failure
Slide 19-

Advantages of PCC Less volume Rapid reversal of the INR to less than 1.3 within 30 minutes Rapid infusion rate – 8.4 mL/minute
Slide 20-

Kcentra dose Usually 25 units/ mL Therefore 3500 units = 140 mL FFP would have been 1050 mL (15mL/kg)
Slide 21-

Reversal AHA Statement: Patients with ICH whose INR is elevated because of VKA should have their VKA withheld, receive therapy to replace vitamin K-dependent factors and correct the INR and receive intravenous vitamin K (class 1; Level of Evidence C). PCCs may have fewer complications and correct the INR more rapidly than FFP and might be considered over FFP (class 2b; Level of Evidence B) rF7a does not replace all clotting factors and so is not recommended
Slide 22-

NOAC AHA Statement: For patients with ICH who are taking dabigatran, rivaroxaban, or apixaban, treatment with FEIBA, other PCCs, or rF7a might be considered on an individual basis. Activated charcoal might be used if most recent dose was taken <2 hours earlier. FEIBA is anti-inhibitor coagulant complex used approved for hemophilia Praxbind is Idarucizumab is humanized monoclonal ab , 5g IV (2 doses of 2.5gms, no more than 15 mins apart)
Slide 23-

Heparin AHA Statement: Protamine Sulfate may be considered to reverse heparin in patients with acute ICH (Class2b; Level of Evidence C)
Slide 24-

AHA guidelines: ICH on heparin Protamine sulfate 1mg per 100 units heparin Dose decreases depending on time since IV heparin was stopped 30-60 min: 0.5-0.75 mg/100 units heparin 60-120 min: 0.375-0.5 mg/100 units heparin >120 min: 0.25 mg/100 units heparin Slow IV infusion, max rate 5 mg/min (high risk of severe hypotension if faster)
Slide 25-

Preventing Hematoma Expansion Platelet Transfusion
Slide 26-

282 ICH cases imaged at onset and at 72 hours, including 70 (25%) taking antiplatelet medication No difference in baseline hematoma volume No difference in hematoma growth at 72 hours No difference in need for surgical evacuation No difference in Rankin score at 90 days No difference in mortality Platelet transfusion for ASA use?
Slide 27-

Platelet Transfusion AHA Statement: The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is uncertain (class 2b: Level of Evidence C) Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively (class 1; Level of Evidence C)
Slide 28-

Used for hemophiliacs with Factor VIII antibodies FAST Trial Phase 3 trial of Factor VII for acute ICH (not on warfarin) Primary outcome: severe disability or death at 90 days 821 patients randomized to placebo, 20, or 80 mcg/kg Treatment started within 4 hours of onset NEJM 2008;358:2127-2137 Factor VII for acute ICH
Slide 29-

Factor VII reduced ICH growth Reduced ICH growth with 80 mcg/kg vs placebo Time mattered: earlier treatment => less growth
Slide 30-

90 day death/severe disability No clinical benefit MI and ischemic stroke absolute risk increased 5%
Slide 31-

Factor 7 AHA Statement: Although rfactor7a can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rF7a and no clear clinical benefit in unselected patients. This rF7a is not recommended (class 3; Level of Evidence A)
Slide 32-

Preventing Hematoma Expansion Metabolic
Slide 33-

Metabolic Glucose should be monitored. Both hyperglycemia and hypoglycemia should be avoided (class 1; Level C) Treatment of fever after ICH may be reasonable (class 2b; Level C) Systemic screening for MI with ECG and cardiac enzyme testing after ICH is reasonable (class 2a; Level C) A formal dysphagia screen should be performed in all patients before initiating oral intake to reduce pneumonia risk (class 1; Level B)
Slide 34-

Complications of ICH Seizures Hydrocephalus DVT/PE
Slide 35-

Seizures Prophylactic antiseizure medication is not recommended (class 3; Level B) Clinical Seizures should be treated with antiseizure meds (Class 1;Level A) Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status that’s out of proportion to degree of brain injury (Class 2a; Level C) and should be treated with antiseizure meds if found to have electrographic seizures on EEG (class 1; Level C)
Slide 36-

Hydrocephalus
Slide 37-

Clinical manifestations of Hydrocephalus Headache Vomiting Drowsiness → Coma
Slide 38-

Indications for EVD EVD as treatment for hydrocephalus is reasonable, esp. in patients with decreased level of consciousness (class 2a; Level B)
Slide 39-

Steroids for ICH: NO!!! Single-center, double-blind randomized trial Dexamethasone versus placebo within 48 hours of onset for 9 days total Trial halted after enrollment of 93 patients due to high rate of complications and no clinical benefit NEJM 1987;316:1229-1233
Slide 40-

DVT Risk of DVT in hemiplegic patients is 10-50% during acute hospitalization Intermittent pneumatic compression must be used immediately (class 1; Level A) Graduated compression stockings are not beneficial to reduce DVT or improve out comes (class 3; Level A) After 1-4 days from onset LMW heparin or unfractionated heparin.
Slide 41-

Intraventricular Hemorrhage Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncertain (class 2b; Level B) The efficacy of endoscopic treatment of IVH is uncertain (class 2b; Level B)
Slide 42-

Multicenter international randomized trial of early surgery versus medical management for ICH Crossover to surgery possible, so NOT strictly a trial of surgery versus medicine Surgeon uncertain about benefit of surgery Randomization within 72 hours of ICH; surgery within 24 hours of randomization Supratentorial ICH only 1033 patients randomized STICH Trial Mendelow et al. Lancet 2005
Slide 43-

STICH Results
Slide 44-

Surgery Patients with cerebellar hemorrhage who are deteriorating neurologically or have brain stem compression or hydrocephalus should under go surgical removal as soon as possible (class 1; Level C) Initial treatment of these patients with ventricular drainage rather than surgical evacuation is not recommended (class 3; Level C) For most patients with supratentorial ICH, usefulness of surgery is not well established (class2b; Level A)
Slide 45-

Surgery Policy of early hematoma evacuation is not clearly beneficial compared to hematoma evacuation when patient deteriorates (Class 2b; Level A)
Slide 46-

ppt slide no 46 content not found
Slide 47-

Deep ICH is like lacunar infarct Deep ICH occurs in: Basal ganglia and thalamus Pons Cerebellum Pathology is similar to lacunar infarct Lipohyalinosis Charcot-Bouchard aneurysms—may be artifactual After deep ICH, annual risk of recurrence is: 2.1% Neurology 2001;56:773-777
Slide 48-

Cerebral amyloid angiopathy The most common risk factor for lobar ICH Infiltration of cortical vessels by amyloid protein Probable CAA: age>55with recurrent lobar ICH After a first lobar ICH, the 2-year cumulative incidence of a second ICH is… 21% N Engl J Med 2000;342:240-245
Slide 49-

CAA-Boston Diagnostic Criteria
Slide 50-

ICH 30-Day Mortality: 30-50%
Slide 51-

Restarting AC Avoidance of long term AC as treatment for nonvalvular afib is probably recommended after AC associated spontaneous lobar ICH due to relatively high risk of recurrence (class 2a; Level B) AC after nonlobar ICH and antiplatelet therapy after an ICH might be considered, particularly when there is strong indication (class 2b; Level B) Optimal timing to resume AC after ICH is uncertain. Avoidance of AC for at least 4 weeks in patients in patients with out mechanical valves, might decrease ICH recurrence (class 2b; Level B)
Slide 52-

Table 9-1 Copyright © 2017 American Academy of Neurology 52
Slide 53-

References Anderson et al. Rapid blood pressure lowering in patients with acute intracerebral hemorrhage. NEJM. 2013; 368: 2355-65. Kazui et al. Enlargement of spontaneous intracerebral hemorrhage. Stroke. 1996; 27(10): 1783-87. Morgenstern et al. Guidelines for the management of spontaneous intracerebral hemorrhage. Stroke. 2010; 41: 2108-2129. Sarode et al. Efficacy and safety of a 4-factor PCC in patients on vitamin K antagonists presenting with major bleeding. Circulation. 2013; 128: 1234-43. Wada et al. CT angiography “spot sign” predicts hematoma expansion in acute intracerebral hemorrhage. Stroke. 2007; 38:1257-62.