Medical and Surgical Management of Intracranial Bleeding

Wendy L. Wright, MD, FCCM, FNCSChief of Neurology and Medical Director of the Neuroscience ICU

Emory University Hospital MidtownAssociate Professor of Neurology and Neurosurgery

Emory University School of MedicineAtlanta, GA

Objectives

• Review anatomy, physiology and causes of intracranial bleeding

• Review management of “surgical” hemorrhages– Epidural hematoma– Subdural hematoma– Subarachnoid hemorrhage– Intraventricular hemorrhage

• Discuss important management principles for intracerebral hemorrhage

• Differentiate management points for cerebral venous sinus thrombosis

Intracranial Hemorrhage

• “Intracranial” hemorrhage could be used to describe many locations of bleeding– Epidural hematoma, subdural hematoma– Subarachnoid hemorrhage– Intraventricular hemorrhage– Intraparenchymal (intracerebral) hemorrhage

• Hypertensive (“Spontaneous”)• Hemorrhage from vascular malformation • Hemorrhagic conversion of ischemic stroke• Traumatic contusion• Tumor• Cerebral venous sinus thrombosis

Intracranial Hemorrhage

• Diagnosis made by head CT– Usually not MRI• May need MRI to look at older, smaller bleeds or to

look for the etiology of the bleed, but non-contrasted head CT remains the imaging study of choice for intracranial hemorrhage

“Surgical” Hemorrhages

• Any intracranial blood should prompt neurosurgical consultation

• However, many do not require neurosurgical procedures

Epidural Hematoma

• Blood collects between the dura and the skull

• Etiology is trauma, usually arterial

• Lucid interval, followed by focal signs, then coma due to increased intracranial pressure

• Surgical management– With seizure prophylaxis

Subdural Hematoma

• Bleeding between the dura and arachnoid

• Etiology is tearing of bridging veins, usually from minor trauma

• Gradually increasing headache and confusion

• Management can be surgical or non-intervention– Seizure prophylaxis

Subarachnoid Hemorrhage

• Etiology– About 50/50 traumatic to vascular– Vascular

• Overwhelming majority are due to aneurysmal rupture• Can be caused by other vascular malformations• “Non-aneurysmal” SAH may be due to venous bleeding

• Symptoms of aneurysmal rupture– Sudden onset worst headache– Stiff neck, seizure, loss of consciousness, focal signs

• Diagnosis– CT– LP, MRI if CT is non-diagnostic

Van Gijn

Liebenberg

Critical Care Management of Patients Following

Aneurysmal Subarachnoid Hemorrhage

Michael N. Diringer • Thomas P. Bleck • J. Claude Hemphill III • David Menon • Lori Shutter •Paul Vespa • Nicolas Bruder • E. Sander Connolly Jr. • Giuseppe Citerio • Daryl Gress •

Daniel Ha¨nggi • Brian L. Hoh • Giuseppe Lanzino • Peter Le Roux • Alejandro Rabinstein •Erich Schmutzhard • Nino Stocchetti • Jose I. Suarez • Miriam Treggiari • Ming-Yuan Tseng •

Mervyn D. I. Vergouwen • Stefan Wolf • Gregory Zipfel

Neurocrit Care (2011) 15:211–240

Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference

Management• Rapid referral to centers with appropriate facilities• Prevent re-bleeding

– Conservative– Secure aneurysm

• Surgical• Endovascular

• Provide general neurocritical care– Prevent/treat other complications– Especially vasospasm– Hydrocephalus– Cerebral edema/Increased intracranial pressure– Cerebral salt wasting– Cardiac and pulmonary dysfunction– Seizures

One common SAH mimic seen in ICU setting:

A CT can be falsely positive for SAH if diffuse cerebral edema is present (for example, after anoxic brain injury). Blood in congested subarachnoid vessels will be hyperdense.

van Gijn

Intraventricular Hemorrhage

• Bleeding into the ventricular system– Where CSF is produced – IVH can cause fatal

hydrocephalus

• Can result from trauma or hemorrhagic stroke

• Management is CSF diversion– Ongoing trials with

intraventricular thrombolysis

Intraventricular Hemorrhage

Intracerebral Hemorrhage

Signs and Symptoms

• Sudden onset headache• Vomiting• Reduced/lost consciousness• Seizure• Stiff neck• Symptoms identical to ischemic stroke– Weakness, numbness, difficulty walking, visual

change, speech difficulties

Diagnosis Made by Head CT

Normal Intracerebral Hemorrhage

Possible Causes of ICH• “Spontaneous” ICH is meant to designate “non-traumatic”

– About 10% of all strokes• Causes may include

– Vascular malformations• Arteriovenous malformation• Telangectasia• Cavernous malformation• Venous malformation

– Tumors• Primary brain tumors- pilocytic astrocytoma• Metastatic tumors prone to bleeding- lung, renal cell, melanoma, papillary thyroid,

hepatocellular

– Infectious lesions• Mycotic aneurysm• Hemorrhagic leukoencephalopathy

– Cerebral venous thrombosis

Underlying Hemostatic Abnormalities

• Patients on oral anticoagulants– 12-14% of ICH– Correct the INR as rapidly as possible

• Vitamin K, fresh frozen plasma, prothrombin complex concentrate• Recombinant factor VIIa?

• Heparin– Reverse with protamine sulfate

• Dose depends on rate of administration and how long ago heparin was stopped

• NTE 5mg/min or can result in hypotension

• Acquired or congenital factor deficiencies• Qualitative or quantitative platelet abnormalities

– Including antiplatelet therapy– Utility and safety of platelet transfusion is unknown

Other Risk Factors for ICH

• Vascular risk factors– Hypertension, diabetes, smoking

• Recent trauma or surgery– Carotid endarterectomy, carotid stenting may cause

hyperperfusion related hemorrhage• Alcohol or illicit drug use• Stimulants (including diet pills, amphetamines),

sympathomimetics• Liver disease, hematologic disorders• Cerebral amyloid angiopathy

Cerebral Amyloid Angiopathy

• Risk for lobar intracerebral hemorrhage• Usually associated with dementia• Risk of bleeding increases with the use of

antiplatelet medication• Microbleeds seen on T2*-weighted gradient

echo MRI• Usually associated with beta amyloid deposits

Lobar Hemorrhage

Initial Management of ICH

• Rapid neuroimaging with head CT or brain MRI is recommended to distinguish ICH from ischemic stroke– And to look for any underlying causes– Especially those that may require surgical management

• Address any underlying bleeding diathesis, antithrombotic agents

• Blood pressure management may be needed acutely to prevent the risk of rebleeding– Highest risk in the first 24-48 hours

Blood Pressure and ICH• Chronic hypertension is a modifiable risk factor of intracerebral

hemorrhage• Frequently and often markedly elevated in acute ICH• Guidelines for goal blood pressure are merely suggestions,

pending the results of ongoing clinical trials– It is “probably safe” to lower markedly elevated blood pressure in the

setting of acute ICH• Maintain cerebral perfusion pressure to ensure adequate blood

flow to the brain, considering possible increased intracranial pressure– CPP= mean arterial pressure-intracranial pressure– Goal CPP also controversial (≥60mm Hg probably adequate; some

recommend a range of 50-70 mmHg)

2007 ICH Guidelines, Broderick

General Management of ICH

• Initial monitoring and management is best accomplished in neurocritical care unit

• Optimal glucose management is unclear; hyperglycemia seems deleterious but hypoglycemia should be avoided

• Fever should be avoided– Maintain normothermia

• The utility of prophylactic anticonvulsant medication remains uncertain– Continuous EEG monitoring should be considered in ICH

patients with depressed mental status out of proportion to their degree of hemorrhage

Medical Treatment of ICH

• 1999 ICH guidelines reported 4 randomized trials– Steroid vs. placebo (2)– Hemodilution vs. best medical therapy (1)– Glycerol vs. placebo (1)

• All showed no benefit– In one of the steroid trials, patients were more

likely to suffer infectious complications

Management of Increased Intracranial Pressure

• Patients with intracerebral hemorrhage often require intracranial pressure monitoring

• CSF diversion via ventriculostomy drain should be considered for patients with hemorrhage extending into the 3rd or 4th ventricles

• Intracranial pressure may be increased before (or without) being reflected on the monitoring device, and treatments for increase in pressure may need to be started based on clinical scenario

• Surgical options may include evacuation of hematoma, mass lesion that caused the bleeding

Surgical Management

• Surgically amenable lesions include:– Cerebellar hematomas causing clinical deterioration and/or

hydrocephalus• Initial treatment with intraventricular hemorrhage alone rather than

surgical evacuation is not recommended

– Lobar hemorrhage >30mL within 1 cm of the surface of the brain may be considered

• Surgical therapy in other situations is usually not considered– Minimally invasive clot evacuation is still experimental– Very early craniectomy may be harmful due the risk of

rebleeding

Withdrawal of Technological Support

• DNR orders are extremely common in ICH– May bias predictive models to make ICH outcomes

look worse than it would if full care was provided• Withdrawal of life-sustaining support is the

most common cause of immediate death in ICH• Recommendations are implement aggressive

full care early after ICH onset and postpone any new DNR orders until at least the second full day of hospitalization

Prevention of Recurrent ICH

• The most consistently identified risk factor for recurrent ICH is lobar location of the initial ICH

• This finding likely represents the association of cerebral amyloid angiography

• Hemorrhage indicative of hypertensive vasculopathy tends to occur in the basal ganglia, thalamus or brain stem

• Other factors linked to recurrence are older age, post-ICH anticoagulation, carriership of the apolipoprotein E ε2 or ε4 alleles, and the greater number of microbleeds on T2*-weighted gradient-echo MRI

Prevention of Recurrent ICH

• Hypertension is the most important currently modifiable risk factor– After acute ICH, a goal target of a normal BP <140/90 is probably

reasonable (<130/80 if diabetes or chronic kidney disease)• Avoidance of long-term anticoagulation for the treatment

of non-valvular afib after ICH is probably recommended after lobar ICH because of the high risk of ICH recurrence

• The decision of whether (and when) to restart anticoagulation or antiplatelet medications depends on how strong the indication for these medications is, and the presumed risk of rebleeding

Cerebral Venous Thrombosis

• CVT accounts for 0.5% to 1% of all strokes• Mostly affects young people, women of

childbearing age• Commonly presents with headache– Though some present with a focal neurological

deficit, decreased level of consciousness, seizures or intracranial hypertension without focal signs

• Insidious onset can create a diagnostic challenge

• 2011 guideline

Cerebral Venous Thrombosis

• A prothrombotic factor or direct cause is identified in about 2/3 of patients

• Diagnosis is usually made by venographic studies with CT (CTV) or MRI (MRV) to demonstrate obstruction of the venous sinuses

Risk Factors• Acquired

– Surgery– Trauma– Pregnancy– Puerperium– Antiphospholipid syndrome– Cancer– Exogenous hormones

• Oral contraceptives

– Infections• Mainly in parameningeal locations• CVT caused by infection is more

common in children

– Mechanical precipitants• Epidural blood patch• Spontaneous intracranial hypotension• Lumbar puncture

• Genetic risks– Inherited thrombophilia/

hypercoaguability• Antithrombin III deficiency• Protein C deficiency• Protein S deficiency• Factor V Leiden positivity• Hyperhomocysteinemia• Mutation G2020A of factor II

• Hematologic disorders– Paroxysmal nocturnal

hemoglobinuria– Polycythemia, thrombocythemia

• Systemic diseases– Systemic lupus erythematosus– Inflammatory bowel disease

Pregnancy and the Puerperium

• Common causes of prothrombotic states• Most pregnancy related CVTs occur in the

third trimester or 6-8 weeks after birth• During the puerperium, additional risk factors

include infection; increasing maternal age; hypertension; vomiting; and instrumental delivery or Cesarean section

Treatment

• Initiate anticoagulation, unless there is a contraindication– In the presence of CVT, intracranial hemorrhage is

NOT an contraindication to anticoagulation• Treat any underlying cause, if able– Including antibiotics for infection, or surgical drainage

of purulent collections of infectious sources associated with CVT when appropriate

• Treat a seizure if one occurs, but routine use of prophylatic antibiotics is not recommended

• Put the treatment algo.

Management of Increased Intracranial Pressure

• Monitor for visual field loss• May require cerebrospinal fluid diversion• Guidelines say that acetazolamide is reasonable to

decrease CSF production• Patients with neurologic deterioration due to severe

mass effect or intracranial hemorrhage causing intractable intracranial hypertension may be eligible for hemicraniectomy

• Steroids are not indicated to treat cerebral edema – Unless needed for another underlying disease

Conclusion

• Intracranial bleeding should prompt neurosurgical evaluation

• Intracranial blood is usually evaluated by emergent non-contrasted head CT

• Intracerebral hemorrhage (ICH) is a distinct form of stroke– Although there is no specific treatment, there are distinct

management expectations• Hypertension is a controllable risk factor

– There is a specific treatment for CVST• Anticoagulation, which is counterintuitive!

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aneurysms: a systematic review. Stroke 1998; 29: 251-256.• van Gijn J, Kerr RS, Rinkel GJ. Subarachnoid haemorrhage. Lancet 2007;369:306-318.• Liebenberg WA, Worth R, Firth GB, Olney J, Norris JS. Aneurysmal subarachnoid

haemorrhage: guidance in making the correct diagnosis. Postgrad Med J 2005; 81:470-473.

• Suarez JI, Tarr RW, Selman WR. Aneurysmal Subarachnoid Hemorrhage. N Engl J Med 2006;354:387-96.

• Bederson JB, Issam AA, Wiebers DO, Piepgras D, Haley EC, Brott T, Hademenos G, Chyatte D, Rosenwasser R, and Caroselli C. Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the stroke council of the American Heart Association. Stroke 2000;31:2742-2750.

• Mayberg MR, Batjer HJ, Darcy R, Diringer M, Halry EC, Heros RC, Sternau LL, Torner J, Adams, HP, Feinberg W, Thies W. Guidelines for the management of subarachnoid hemorrhage. Circulation 1994; 90 (5): 2592-2605.

• Broderick J, Connolly S, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults: 2007 Update: A Guideline From the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation 2007;116:e391-e413.