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"The Knowledge we take into our shifts does matter"
Once you've read the summary below, come back and watch this lecture from 2017.
10% of strokes are due to intracerebral haemorrhages (ICH). This type of stroke has a mortality of 30-40%. It increases with age and with anticoagulation. Approximately 73% of ICH is attributable to uncontrolled hypertension.
Two cerebral small vessel pathologies that account for the majority of ICH are; arteriosclerosis and cerebral amyloid angiopathy.
How do Bleeds cause brain injury?
Brain tissue is injured by:
CT is the most widely used modality to rule out ICH. It also provides useful information on haematoma volume. Haematoma expansion usually occurs within the first 24 hours and is an independent predictor of increased mortality.
Repeat CT to evaluate haematoma expansion and oedema, is helpful especially if the patients neurological status deteriorates.
Investigation of the cause of the ICH is important as it may affect acute treatment and prognosis.
Patients who are <70yo and who have not had a hypertensive deep territory ICH, have a 1 in 4 to 1 in 7(depending on age) chance of an underlying vascular cause such as:
Catheter intra-arterial DSA is the gold standard for determining the macrovascular cause with highest yield being for:
Blood Pressure Control
Patients with acute ICH present with increased BP, which is associated with haematoma expansion, neurological deterioration and mortality.
Should we treat raised Blood Pressure? The results from major trials have been equivocal.
There are 2 major trials:
Studies have also shown that large reductions ie >60mmHg in the first hour was associated with worst outcomes. Therefore lowering the SBP too quickly should be avoided.
Smooth continuous lowering of blood pressure to a systolic blood pressure of 130-140mm Hg in acute ICH and SBP of 150-220mm Hg, is safe and may improve functional outcome.
Avoid lowering the SBP to < 130 mm Hg as it could be potentially harmful.
The BP lowering drug used should have a:
The RIGHT-2 (Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial), used transdermal nitroglycerine in ambulance, had worst outcomes with larger haematoma and oedema volumes. Venous vasodilators may be harmful due to unopposed venodilatation and its effects on haemostasis and ICP.
Haemostasis and Coagulopathy
Haemorrhage expansion and poor outcome is increased in patient with ICH on anticoagulation. Rapid reversal is required.
If the patient is on Warfarin (Vitamin K antagonist)
Antiplatelet therapy at time of haemorrhage has been associated with increased mortality and an unfavourable functional outcome.
There is no evidence that platelet transfusions, Desmopressin and TXA result in benefit to patients with ICH on antiplatelets.
One group which might benefit are those that are receiving an emergency craniotomy for haematoma removal. Platelet transfusion may reduce postoperative haemorrhage volume.
30% chance of developing a significant arrhythmia.
Older patient with large bleed ie >5cm had a higher likelihood of developing an arrhythmia. Most are in the first 24-72 hours.
Fever in ICH is associated with increased clinical severity and worst outcomes. There is not great evidence that treating fever results in better outcomes.
Therapeutic hypothermia and other means of reducing temperature are a means of reducing perihaematoma oedema, however no clinical benefit has been demonstrated.
Seizures and Antiseizure Medications
New onset seizures in ICH occur in about 28% of patients and tend to occur in the first 24 hours.
The benefit of prophylactic use of anti-seizure medication is unclear.
Small studies initially showed some benefit with Sodium Valproate and worst outcomes with Phenytoin
Recent studies have not shown consistent harm or benefit.
Neuroinvasive Monitoring, ICP and Oedema Management.
Ventricular drainage should be performed in intraventricular haemorrhage.
Hyperosmolar therapy can be used to transiently reduce intracranial pressure, however the use of prophylactic hyperosmolar agents is uncertain.
Corticosteroids should not be administered for treatment of elevated ICP in ICH.
ICH score has been used for severity, but its use in clinical practice has not been clarified.