ICH Management Andrew M. Demchuk MD FRCPC Director, Calgary Stroke - - PowerPoint PPT Presentation

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ICH Management Andrew M. Demchuk MD FRCPC Director, Calgary Stroke - - PowerPoint PPT Presentation

May 06, 2023 235 likes •674 views

ICH Management Andrew M. Demchuk MD FRCPC Director, Calgary Stroke Program Pillar 2 Chair APSS (Acute Care and Emergency Services) Heart and Stroke Foundation Chair in Stroke Research Professor University of Calgary Epidemiology of ICH

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ICH Management

Andrew M. Demchuk MD FRCPC Director, Calgary Stroke Program Pillar 2 Chair APSS (Acute Care and Emergency Services) Heart and Stroke Foundation Chair in Stroke Research Professor University of Calgary

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Epidemiology of ICH

Comprises 15% 10% of stroke in the NA/Europe 30% in the developing world 6 month prognosis 40% dead 40% disabled and dependent 20% independent

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Mechanism - ICH

Hypertension

฀ Treat the hypertension – may NOT be

necessary acutely

Drugs (eg. PPA, cocaine)

฀ Lifestyle changes

Amyloid angiopathy

฀ No treatment

AVM

฀ Surgery, radiosurgery, embolization

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Investigation of ICH for underlying etiology

Noncontrast CT +/- CT-angiography MRI with GRE/SWI Conventional angiography

Hypertension Amyloid angiopathy Arteriovenous malformation Intracranial aneurysm Cavernous angioma Dural venous sinus thrombosis Intracranial neoplasm Coagulopathy Cocaine or alcohol use

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Severe Amyloid Angiopathy Pattern

Gradient echo imaging

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Hypertensive Arteriolosclerosis Pattern

Gradient echo imaging

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Acute CT for prognosis: ICH Volume Measurement, IVH, location

A x B x C / 2 A – greatest width B – greatest length C – depth

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Prognosis

  • Size and location of hematoma
  • Presence of IVH
  • Clinical deficit
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2.5 hours after symptom onset

6.5 hours after onset, with enlargement of the hematoma due to ongoing bleeding

“Early Hematoma Growth”

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Dripping with each passing minute

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Case 1

  • 48 year old hypertensive
  • Onset 2 hours ago
  • Right hemiplegia
  • Basal ganglia ICH 20 ml
  • Systolic BP 210
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<150 systolic BP lowering marginal in ICH

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More aggressive BP lowering in ICH no effect

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ICH Management

Comprehensive stroke centre if severe deficits? BP <140 mmHg systolic but not much lower best

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Case 2

  • 78 year old afib on warfarin
  • Subcortical ICH 6 ml
  • Systolic BP 140
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Anticoagulation major risk for hematoma expansion

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Prothrombin Complex Concentrate for Coagulopathy

Clotting factors: FII, VII, IX and X, protein C and S.

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Prothrombin Complex Concentrate for Coagulopathy

1000U INR 1.5-3 2000U if INR 3-5 3000U if INR >5

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Praxbind bolus for Dabigatran associated ICH

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ICH Management

Urine toxicology screen

CT/CTA should be standard INR STAT crucial

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Our Imaging in ICH Philosophy:

Good Quality Plain CT and mCTA brain to view for abnormal arteries/veins and view the leakpoint! Don’t Leave the ED Without It!

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Spot Sign Contrast Extravasation

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rFVIIa ICH Trials Failed

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Logarithmic curve of bleeding with increasing hemostasis then contraction

time ICH volume

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Logarithmic curve of bleeding with increasing hemostasis then contraction

time ICH volume

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Future Directions

  • Hemostasis needs to be initiated much earlier
  • Spot sign predicts HE but needs refinement
  • Hemostatic ICH trial design should focus on:
  • ultraearly time windows (<2h)
  • Deferral or waiver of consent
  • pre-hospital setting (CT ambulance)
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Emerging acute tx of ICH

Hematoma expansion prevention therapy Surgical evacuation of ICH Thrombolysis in IVH

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ICH Surgical Decision Making?

D E

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When to Operate?

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Hanley D et al. ISC 2012

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Intraventricular Hemorrhage

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tPA instillation 1 mg q8h dual vent drains

CLEAR IVH Phase 3 trial

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Most ICHs Should Be Care For At CSCs

IV TPA Delivery Tertiary Care (Telestroke, Transfers, Education, etc.) Comprehensive Stroke Centre Primary Stroke Centre Proposed Primary Stroke Centre

Calgary Zone

1,326,115

Calgary serves as the only comprehensive care centre in the south and the primary care centre for an area with over 1.3 million residents (2009)

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Key Messages

  • ICH 2nd most common stroke
  • BP control to systolic ~140 mmHg quickly
  • Correction of coagulopathy needed STAT
  • Bleeding occurs very early which has

limited development of hemostatic tx.

  • Surgery offered in moderate sized cerebral
  • r large cerebellar ICH
  • Minimally invasive surgery promising
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Thank You for your attention