Neurosurgery notes/Vascular/Haemorrhagic diseases/Intracerebral haemorrhage (ICH)/Treatment ICH

Treatment ICH

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Intracerebral haemorrhage (ICH)

Initial management of ICH: No uniform agreement

  • INTERACT3 trial:
    • Using this package: All target maintained in patients for 7 days
      • BP:
        • Target systolic blood pressure of less than 140 mm Hg within 1 h of the initiation of treatment, with a systolic blood pressure of 130 mm Hg being the threshold for the cessation of treatment
      • BM: ASAP but careful about hypoglycaemia
        • 6·1–7·8 mmol/L for patients without diabetes
        • 7·8–10·0 mmol/L for patients with diabetes
      • Temp
        • Body temperature of < 37·5°C within 1 h of initiation
      • Coag
        • INR < 1·5 within 1 h of treatment.
        • Reversal of abnormal anticoagulation in those taking warfarin using
          • Fresh frozen plasma OR
          • Prothrombin concentrate complex
        Functional outcome at 90 days in the care bundle and usual care groups, according to scores on the mRS. Raw distribution of scores on the mRS at 90 days. Scores on the mRS range from 0 to 6, with 0 indicating no symptoms, 1 indicating symptoms without clinically significant disability, 2 indicating slight disability, 3 indicating moderate disability, 4 indicating moderately severe disability, 5 indicating severe disability, and 6 indicating death. There was a significant difference between the care bundle group and usual care group in the overall distribution of scores (common odds ratio, indicating a lower odds of worse global function outcome on the mRS, 0·86 [95% CI 0·76–0·97]; p=0·015). mRS=modified Rankin Scale.
        Functional outcome at 90 days in the care bundle and usual care groups, according to scores on the mRS. Raw distribution of scores on the mRS at 90 days. Scores on the mRS range from 0 to 6, with 0 indicating no symptoms, 1 indicating symptoms without clinically significant disability, 2 indicating slight disability, 3 indicating moderate disability, 4 indicating moderately severe disability, 5 indicating severe disability, and 6 indicating death. There was a significant difference between the care bundle group and usual care group in the overall distribution of scores (common odds ratio, indicating a lower odds of worse global function outcome on the mRS, 0·86 [95% CI 0·76–0·97]; p=0·015). mRS=modified Rankin Scale.
  • Patient manage in ICU
  • HTN: controversial issue
    • HTN causes ICH but ICH can inc. ICP requiring HTN to maintain perfusion.
    • Treatment HTN to 140/90
  • Intubate
  • Maintain BM 10
  • Maintain normothermia (?37)
  • Anti convulsants
    • If seizure present start
    • Optional for prophylactic: esp for lobar haemorrhage
    • 500mg Keppra BD
  • Haemostatic issues
    • Check coag, platelet count and platelet function
    • Platelets
      • Transfuse when <50 try and keep it above 75
      • Give platelets to patients who are on antiplatelets
    • Haemostatic agent
      • NovoSeven (recombinant activated coagulation factor VII): given IV within 4hrs of onset
        • rFVIIa ==+ Tissue factor causes
          • Thrombin production
          • Converts factor X to Factor Xa --> resulting a thrombin burst at the site of damage
        • Halflife 2.6hrs expensive 10,000 dollar per dose
        • FASTrial:
          • Hemostatic therapy with rFVIIa reduced growth of the hematoma but did not improve survival or functional outcome after intracerebral hemorrhage
        • Phase 3 will be done in 2025
  • Steroids: controversial
    • No benefit and has significant complications: primary infectious, GI, bleeding and DM
    • Only use if significant peri haemorrhage oedema on imaging
    • 4mg dex IV QDS taper over 7=14 days
  • Treatment intracranial HTN presumptively
    • Mannitol and/or furosemide
    • Consider ICP monitoring
  • Follow electrolyte and osmolarity
    • SIADH risk
    • Treats hyperglycaemia aggressively
  • Anticoagulation following ICH for Prosthetic heart valves, previous cardio embolic stroke, AF
    • Big dilemma: can increase size of ICH
    • Continuing anticoagulation for no other alternatives does not always end in disastrous results
    • Warfarin:
      • Probability of having an ischemic stroke at 30 days following cessation of warfarin for a median of 10 days are
            • Risk of ischaemic stroke
            Warfarin taken for
            Recommendation
            2.9%
            Prosthetic heart valves
            1-2 wks off anticoagulation the return to it
            2.6%
            AF
            Avoid anticoagulation
            4.8%
            Ischaemic stroke
    • Antiplatelet therapy after ICH is not associated with a substantially increased risk of recurrent ICH
    • Use heparin free haemodialysis
  • Indication for Surgery vs Medical treatment for ICH
      • Medical
      • Minimal symptomatic lesion
        • Pt with subtle hemiparesis
      • Situation where patient has very little chance of good outcome
        • High ICH score
        • Massive haemorrhage with significant neuronal destruction
        • Large haemorrhage in dominant hemisphere
        • Poor neurological condition
          • GCS<=5
          • Loss of brainstem f(x): pupils, posturing
        • Age >75 yrs
      • Severe coagulopathic: might still do surgery if brainstem is compressed
      • Deep bleed: putamen/thalamic bleed: surgery no better than medical tx
      Surgery
      • Lesion with large mass effect
      • Neurology due to raised ICP
      • Medium size haematoma (10-30cm3)
        • Too small: would not have enough mass effect
        • Too big: associated with poor outcome (severe disability)
      • Medical refractory raised ICP
        • Surgery will reduce ICP but whether it improves outcomes no one knows
      • Rapid deterioration: Patient with brain stem compression
      • Location of bleed is superficial
        • Lobar type
        • Cerebellar
        • External capsule
        • Non dominant hemisphere
      • Young patient (<50)
        • Tolerate surgery better
        • The deteriorate faster with mass effect because they don’t have cerebral atrophy
      Studies
      STICH, 2005
      • Pragmatic
      • Conservative management vs early surgery (24hrs of randomization) of clot evacuation in patients with supratentorial spontaneous ICH in patients with poor or good prognosis
      • Inclusion
        • Clinician wasn’t not aware of the benefit of either treatment
        • GCS>5
        • Haematoma >2cm
      • Exclusion
        • Aneurysmal bleed
        • Infratentorial bleed
        • Extension of bleed into brainstem
        • Any co-morbidity factor that might affect assessment of outcome
      • Glasgow Outcome Scale score at 6 months
        • Good outcome is defined as
          • > moderate disability for good prognosis patient
          • > severe disability for poor prognosis patients
      • Results: no statistical significant difference between
      STICH II 2013
      • Done because STICH showed in post hoc that superficial haematoma has better outcome when evacuated
      • Conservative management vs early surgery (12hrs of randomization) of clot evacuation in patients with supratentorial superficial spontaneous ICH in patients with poor or good prognosis
      • Inclusion
        • Spontaneous lobar intracerebral haemorrhage on CT scan
        • Superficial (≤1 cm from the cortical surface of the brain)
        • 10-100ml
        • 48 h of ictus
        • Best motor score on the Glasgow Coma Score (GCS) of 5 or 6,
        • Best eye score of 2 or more (ie, were conscious at randomisation).
      • Exclusion
        • The haemorrhage was due to an aneurysm or angiographically proven arteriovenous malformation;
        • Was secondary to tumour or trauma;
        • Involved the basal ganglia, thalamic, cerebellar, or brainstem regions;
        • There was any intraventricular blood.
        • Any severe pre-existing physical or mental disabilities or comorbidities that could interfere with the assessment of the outcome
      • Outcome measure
        • Extended Glasgow Outcome Scale (GOSE) at 6 months based on age volume of clot and GCS
          • Good outcome is defined as
            • > moderate disability for good prognosis patient
            • > severe disability for poor prognosis patients
      • No statistical significant difference in outcomes but might be due to small numbers and 21% medically treatment patient further went on to have surgery when they were more poorly hence could have benefited if surgery was earlier
      Stereotactic aspiration
      • Further reduces damage to unaffected brain
      • Unrandomized studies showed good outcome
      • Chen 2011 et al frameless stereotaxy, secured to the skull, and then connected to a drainage bag. Urokinase was injected into the hematoma 2 to 3 times per day for 2 to 4 days, and the system was allowed to drain continuously
      Minimally Invasive Surgery Plus rt-PA for Intracerebral Haemorrhage Evacuation (MISTIE) Trial phase 3 (2019)
      • Stereotactic catheter placement and clot aspiration followed by injection of rtPA through the catheter into the hematoma. Injections were performed every 8 hours for up to nine doses.
      • INCLUSION:
        • > 18 years
        • Spontaneous, non-traumatic,
        • Supratentorial intracerebral haemorrhage
        • > 30 mL
        • Due to cerebral small-vessel disease,
        • Glasgow Coma Scale (GCS) score of 14 or less or National Institutes of Health Stroke Scale (NIHSS) score of 6 or higher,
        • mRS score of 0 or 1 before the bleed,
        • Intracerebral haemorrhage that remained the same size (growth <5 mL) for at least 6 h after diagnostic CT.
      • EXCLUSION:
        • We did not enrol patients with expressed care limitations or those deemed to have life-threatening mass effect requiring surgery.
      • Outcome:
            • mRS and eGOS scores 365 days after stroke in the modified intention-to-treat analysis set. mRS scores range from 0 (no disability) to 6 (death). eGOS scores range from 8 (upper good recovery) to 1 (death). 110 (44%) of 249 patients in the MISTIE group and 100 (42%) of 240 patients in the standard medical care group had an mRS score of 3 or less 365 days after stroke. 139 (56%) of 249 patients in the MISTIE group and 140 (58%) of 240 patients in the standard medical care group had an mRS score of 4–6 365 days after stroke. mRS scores were missing for 10 of 499 patients: six patients were lost to follow-up and four patients withdrew. 94 (39%) of 244 patients in the MISTIE group and 84 (36%) of 234 patients in the standard medical care group had achieved eGOS scores of 4–8 (upper severe disability to upper good recovery) 365 days after stroke, and 150 (61%) patients in the MISTIE group and 150 (64%) patients in the standard medical care group had eGOS scores of 1–3 (lower severe disability to death) 365 days after stroke. eGOS scores were missing for 21 of 499 patients, of whom 11 completed the study with no eGOS reported, six were lost to follow-up, and four refused further participation. Detailed ordinal measures for mRS and eGOS are shown in the appendix. mRS=modified Rankin Scale. eGOS=extended Glasgow Outcome Scale.
            mRS and eGOS scores 365 days after stroke in the modified intention-to-treat analysis set. mRS scores range from 0 (no disability) to 6 (death). eGOS scores range from 8 (upper good recovery) to 1 (death). 110 (44%) of 249 patients in the MISTIE group and 100 (42%) of 240 patients in the standard medical care group had an mRS score of 3 or less 365 days after stroke. 139 (56%) of 249 patients in the MISTIE group and 140 (58%) of 240 patients in the standard medical care group had an mRS score of 4–6 365 days after stroke. mRS scores were missing for 10 of 499 patients: six patients were lost to follow-up and four patients withdrew. 94 (39%) of 244 patients in the MISTIE group and 84 (36%) of 234 patients in the standard medical care group had achieved eGOS scores of 4–8 (upper severe disability to upper good recovery) 365 days after stroke, and 150 (61%) patients in the MISTIE group and 150 (64%) patients in the standard medical care group had eGOS scores of 1–3 (lower severe disability to death) 365 days after stroke. eGOS scores were missing for 21 of 499 patients, of whom 11 completed the study with no eGOS reported, six were lost to follow-up, and four refused further participation. Detailed ordinal measures for mRS and eGOS are shown in the appendix. mRS=modified Rankin Scale. eGOS=extended Glasgow Outcome Scale.
        • MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage.
      ENRICH trial
      • 30-80mls, <80 yrs, surg <24 hrs, mRS 0/1, GCS 5-14
      • Mean score on the utility-weighted modified Rankin scale at 180 days was (difference, 0.084)
        • 0.458 in the surgery group
        • 0.374 in the control group
      • Percentage of patients who had died by 30 days was
        • 9.3% in the surgery group
        • 18.0% in the control group.
      • 3.3% in the surgery group had postoperative rebleeding and neurologic deterioration.
      SWITCH trial
      • Within 72 hrs
      • Severe intracerebral haemorrhage involving the basal ganglia or thalamus
      • Intervention
        • Decompressive craniectomy (diameter ≥12 cm) without haematoma evacuation.18,19 The bone flap was reinserted within 1–5 months after decompressive craniectomy, followed by a postoperative CT scan
        • Best medical treatment
          notion image
        • Just convert death to poor functional outcome.
      PATCH study
      • Bottom line
        • Platelet transfusion seems inferior to standard care for people taking antiplatelet therapy before intracerebral haemorrhage.
        • Platelet transfusion cannot be recommended for this indication in clinical practice.
      TXA in ICH: TICH 2 trial
      • Functional status 90 days after intracerebral haemorrhage did not differ significantly between patients who received tranexamic acid and those who received placebo, despite a reduction in early deaths and serious adverse events.
  • Using tPA to lose clot to maintain catheter patency
    • No RTA but shown anecdotally is safe
    • Do not use: If unsecured aneurysm or untreated AVM or vascular malformation
    • Method
      • 2-5mg of TPA through catheter and lock for 2 hours
  • Using tPA to reduce clot volume:
    • Hypothesis: reduce pressure, reduce neurotoxicity of bld
    • CLEAR II study
      • 12x 1mg tPA every 8hrs
      • Results
        • More survivors with poorer outcome
        • Lower 30d mortality 15% vs 85%
        • Similar functional outcome when use saline instead of tPA
      • Can just use saline instead of tPA

Management of cerebellar haemorrhage

  • Treatment conservative
    • GCS>= 14 and
    • Haematoma <4cm diameter
  • Surgical treatment
    • Indication
      • GCS<14 or
      • Haematoma >=4cm
  • If no brain stem reflex and patient is flaccid quadriplegic —> intensive therapy is not indicated
  • If hydrocephalus
    • EVD controversial
      • But don’t over drain —> upward herniation
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