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Intracranial Haemorrhage

Barbara Stanley FRCA Consultant Neuroanaesthetist

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Where to start??

• Intracranial hemorrhage (MeSH term) + 2010 – 2014 = 4839

• Review articles only = 246 • Each type of bleed – last 5 years on PubMed

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EDH• BTF Guidelines http://tbiguidelines.org/glHome.aspx?gl=3• Indications for Surgery• An epidural hematoma (EDH) greater than 30 cm3 should be

surgically evacuated regardless of the patient’s Glasgow Coma Scale (GCS) score.

• An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center.

• Timing It is strongly recommended that patients with an acute EDH in coma (GCS score < 9) with anisocoria undergo surgical evacuation as soon as possible.

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• Extradural haematoma—To evacuate or not? Revisiting treatment guidelines Z. Zakaria et al. Clinical Neurology and Neurosurgery 115 (2013) 1201–1205– “We described three cases of EDH; all were

managed differently based on their GCS at presentation, whether the EDH was supratentorial or in the posterior fossa, volume of EDH and degree of midline shift (MLS) on CT scan.”

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CT scan showed a large EDH in the right parieto-occipital region with a MLS of 5mm(Fig. 1a). Small temporal contusions were also noted on the scan. The blood volume was 90cm3. He was admitted for neurologic observation and analgesicswere administered. After a few hours, his symptoms receded, and 24 h later he remained well. A repeat CT scan showed no change in the features of the EDH.

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EDH

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Acute SDH• BTF Guidelines: http://tbiguidelines.org/glHome.aspx?gl=3• Indications for Surgery An acute subdural hematoma (SDH) with a

thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient’s Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring.

• A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg.

• Timing In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.

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– “outcomes have historically been worse for patients with ASDH with mortality rates between 40 and 68%.”

– “uncertainty remains as to the role of decompressive craniectomy (DC).”

– A more recent international survey undertaken during 2011 demonstrated that more than half of the respondents perform a primary DC for evacuation of ASDH in more than 25% of their patients

– The DECRA study failed to show clinical benefits with early/neuroprotective bifrontal DC for severe diff use TBI (without mass lesions). 5 The RESCUEicp trial (www.rescueicp.com), which is examining the role of DC as a last-tier therapy for post-traumatic refractory intracranial hypertension ( > 25 mmHg), is ongoing and has now recruited more than 90% of the required sample size

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• Surgical management of acute subdural haematomas: current practice patterns in the United Kingdom and the Republic of Ireland. A. G. Kolias et al. British Journal of Neurosurgery, June 2013; 27(3): 330–333– uncertainty remains as to the role of decompressive

craniectomy (DC).– The survey findings confirm that there is a significant

variation in the use of primary DC for the evacuation of ASDH even within neurosurgical centres in the UK and Ireland. A recent international survey showed that a higher proportion of neurosurgeons from other European countries (44%) as compared with UK/Irish neurosurgeons (21%) use primary DC in more than half of ASDH cases (p > 0.001).

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And on the subject of decompressive craniectomy…..

• The current role of decompressive craniectomy in the management of neurological emergencies S. Honeybul, & K. M. Ho. Brain Inj, 2013; 27(9): 979–991

• RCT’s only for DC in TBI and Ischaemic Stroke• In the context of ischaemic stroke the results of the three

randomized controlled trials have provided unequivocal evidence that surgical decompression reduces mortality– In the pooled analysis of the three European stroke trials it was concluded

that the procedure increases the number of patients with a favourable outcome at 1-year after surgery [135]. However, in this review, patients with a modified Rankin Scale (mRS) score of 4 (unable to walk or attend to their own bodily needs without assistance) were considered as a favourable outcome

The findings confirmed that decompressive craniectomy was associated with an increased risk of survival with an unfavourable outcome

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• Age and Salvageability: Analysis of Outcome of Patients Older than 65 Years Undergoing Craniotomy for Acute Traumatic Subdural Hematoma. Taussky et al. WORLD NEUROSURGERY 78 [3/4]: 306-311, 2012– Thirty-seven consecutive patients (54% women, 46% men) were treated

for aSDH by means of craniotomy and duraplasty. Median age was 73 years (interquartile range, 10 years). Thirty patients (81%) had significant comorbidities and 43% of patients were treated by anticoagulation or thrombocyte aggregation inhibitors. Median initial Glasgow coma scale score was 8 (interquartile range, 7), and 51% had pupillary abnormalities. Perioperative morbidity occurred in 12 of 37 patients (32%), and 13 patients died in the postoperative period (35%). Overall outcome according to Glasgow outcome scale (GOS) was favorable (GOS, 4 and 5) in 15 of 37 patients (41%); severely disabled (GOS, 3) in 8 of 37 (22%), and unfavorable (GOS, 1 and 2) in 14 of 37 (38%)

Good commentary Craniotomy for Acute Subdural Hematoma in the Elderly: Not as Bad as You Thought WORLD NEUROSURGERY 78 [3/4]: 231-232,

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• Acute Subdural Hematoma Without Subarachnoid Hemorrhage Or Intraparenchymal Hematoma Caused By Rupture Of A Posterior Communicating Artery Aneurysm: Case Report And Review Of The Literature. M. Mrfka et al. The Journal of Emergency Medicine, Vol. 44, No. 6, pp. e369–e373, 2013– Only 27 cases 1980 to 2011, a female preponderance. After treatment,

only 33.3% of the 27 cases had a poor prognosis. The majority of these aneurysms (59.26%) are located at the posterior communicating artery

– In the presence of an aneurysm, evacuation of the hematoma and clipping of the aneurysm dictate the best strategy.

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• Aneurysmal acute subdural hemorrhage: Prognostic factors associated with treatment C. Kulwin et al. Journal of Clinical Neuroscience 21 (2014) 1333–1336

• Patients with aneurysmal SDH present in poor clinical grade compared to historical controls without hematomas. However, poor-grade presentation resulted in a good clinical outcome in 35% of patients. Clinical grade at the time of intervention, aneurysm size, and age correlated with outcome.

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Chronic SDH• Glasgow Coma Scale on admission is

correlated with postoperative Glasgow Outcome Scale in chronic subdural hematoma. A Amirjamshidi, et al. Journal of Clinical Neuroscience 14 (2007) 1240–1241– 128 consecutive patients who underwent burr-

hole surgery for drainage of the hematoma between June 1996 and March 2004. Mean age of patients was 57.2 years (oldest 88yrs) There was a significant correlation between GCS and GOS (Spearman rank correlation coefficient = 0.557; p < 0.01)

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• Chronic subdural hematoma patients aged 90 years and older. Stippler. M et al. Neurol Res. 2013 Apr;35(3):243-6

– Twenty-one patients aged 90. 76% (n = 16) underwent surgery - 8 craniotomy and 10 burr-hole craniostomy were performed. Median presentation GCS was 14. Disposition to home, rehabilitation facility, nursing home, hospice, or death were not significantly different between conservative and operative groups (P = 0.10) when compared to the GCS at admission. nor was admission GCS (P = 0.59). The size of SDH was significantly (P = 0.02) larger in the operative group. Overall, only 24% (n = 5) of patients were discharged home and mortality rate 24%

BUT Please note: Nearly one third of the patients in the surgical group were sent to hospice or died. None of the patients in the conservative group died and none of them showed deterioration on the GCS at the time of discharge

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• Chronic Subdural Hematoma in Patients Over 90 Years Old in a Super-Aged Society. Tabuchia. S et al J Clin Med Res.2014;6(5):379-383– retrospectively review 20 consecutive patients– Neurosurgical treatment was performed under

local anesthesia – burr hole only– After surgery, 66.7% of patients could return home

directly from hospital– The mortality rate of acute hospitalization was 0%

in the surgery group and 12.5% in the conservative group due to general complications resulting from poor physical status

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SAH• Guidelines for the Management of Aneurysmal Subarachnoid

Hemorrhage A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association. Stroke. 2009;40:0-0 – In ISAT, post treatment SAH occurred at an annualized rate of 0.9%

with surgical clipping compared with 2.9% with endovascular treatment. Currently available evidence indicates that the rate of incomplete obliteration and recurrence is significantly lower with surgical clipping than with endovascular treatment

– Timing of surgery after SAH was significantly related to the likelihood of preoperative rebleeding (0 to 3 days, 5.7%; 4 to 6 days, 9.4%; 7 to 10 days, 12.7%; 11 to 14 days, 13.9%; and 15 to 32 days, 21.5%).

– ISAT, the mean time to treatment was 1.1 days for endovascular coiling versus 1.8 days for surgery; in that study, there were fewer preoperative rebleeds in the endovascular group

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So…• If it has bled – secure it (Class I, Level of Evidence B).• Do it early (Class IIa, Level of Evidence B) – and in a centre

where it’s done a lot (Class IIa, Level of Evidence B).• If it’s amenable to coil or clip – coil it (Class I, Level of

Evidence B) ISAT showed endovascular coiling is associated with better outcomes at 1 year than surgical clippingif both surgeon and radiologist equally experienced

• Anaesthetists – minimise hypotension during securing(Class IIa, Level of Evidence B).

• For Vasospasm – Nimodipine (Class I, Level of Evidence A). Normovolaemia (Class IIa, Level of Evidence B). Triple H therapy (Class IIa, Level of Evidence B). Angioplasty or intraluminal vasodilators (Class IIb, Level of Evidence B).

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• Subarachnoid hemorrhage: an update for the intensivist. A. Coppadoro, G. Citerio. Minerva Anestesiol 2011;77:74-84– After five years, relative risk of death is less for patients who

have undergone coiling treatment, but no difference is demonstrated in the probability of good neurological status

– Risk of reintervention with coiling is higher than clipping– Conversely, risk of rebleeding at eight years does not appear

to be dependent on the type of treatment– Expert Committee of the American Academy of Neurology

supports the use of TCD on the basis that severe spasms can be identified with fairly high reliability.

– Emerging evidence shows CT perfusion (CTP) as the imaging technique of choice for early assessment of vasospasms. Unlike TCD it is predictive of secondary cerebral infarction

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• vasopressor-induced elevation of mean arterial pressure causes a significant increase in regional cerebral blood flow and brain tissue oxygenation whereas volume expansion only slightly increased flow and reversed the positive effect on tissue oxygenation

• Clazosentan, an endothelin receptor antagonist. showed a dose-dependent reduction in angiographic vasospasms in comparison with a placebo in a recent RCT of 413 patients (CONSCIOUS Trial ongoing)

• MESH trial magnesium treatment tended to decrease the occurrence of DCI and poor outcome but was not statistically significant

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• Subarachnoid Haemorrhage and cerebral vasospasm – Literature review. AV Ciurea et al, Journal of Medicine and Life Vol. 6, Issue 2, April-June 2013, pp.120-125– Vasospasm and Nitric Oxide Pathway– Vasospasm and Endothelin Pathway– Vasospasm and Hypoxia Inducible Factor-1 (HIF-1)– Vasospasm and Inflammation– Vasospasm / Early Brain Injury and Oxidative Stress– Vasospasm and Apoptosis– Statin and Vasospasm– Thrombin and Vasospasm

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• Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Dankbaar et al. Critical Care 2010, 14:R23– There is no good evidence from controlled studies

for a positive effect of triple-H or its separate components on CBF in SAH patients. In uncontrolled studies, hypertension seems to be more effective in increasing CBF than hemodilution or hypervolemia

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• Subarachnoid hemorrhage from intracranial aneurysms during pregnancy and the puerperium. Kataoka H et al. Neurol Med Chir (Tokyo). 2013;53(8):549-54

• > 50% IA ruptures occur in third trimester• Both mother and foetus benefit from surgery – maternal

mortality in surgical group 11% vs 63% in non-surgical and foetal mortality is 5% vs 27%

• If gestation >28 weeks – c-section and clipping. If not – clip whilst maintain pregnancy

• If ICP high – clot evac and EVD whilst foetal monitoring. If foetal distress – suspend ICP procedure and c-section

• Coiling – radiation absorption is low but heparinization and re-bleed risk is greater – so clipping better – but not unsafe (Endovascular treatment in pregnancy. Neurol Med Chir (Tokyo). 2013;53(8):541-8 for an excellent summary)

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ICH• Guidelines for the Management of Spontaneous Intracerebral

Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Morgenstern et al. Stroke.2010;41:2108-2129– Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic

stroke from ICH (Class I; Level of Evidence: A).– In patients presenting with a systolic BP of 150 to 220 mm Hg, acute lowering

of systolic BP to 140 mm Hg is probably safe (Class IIa; Level of Evidence: B).– Patients with ICH whose INR is elevated due to OACs should have their

warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K (Class I; Level of Evidence: C). PCCs have not shown improved outcome compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP (Class IIa; Level of Evidence: B). rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH (Class III; Level of Evidence: C).

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• Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise (Class I; Level of Evidence: B).

• For most patients with ICH, the usefulness of surgery is uncertain (Class IIb; Level of Evidence: C).

• Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding (Class III; Level of Evidence: B)

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• Surgery for Intracerebral Hemorrhage Moving Forward or Making Circles? Flaherty & Beck. Stroke.2013;44:2953-2954.

• 2 basic rationales for surgical removal of blood after. ICH.– to reduce mass effect, to improve intracranial pressure and brain

perfusion and to prevent dangerous compartment shifts and herniation

– removal of blood products may reduce secondary injury caused by blood breakdown and adverse biochemical or inflammatory processes

– STICH I, published in 2005, remains the largest trial (with a sample size of 1033 subjects) to test this hypothesis) no benefit in 6-month favorable outcome in the surgical group (26%) compared with the medical group (24%, P=0.41

– subjects with lobar ICH ≤1 cm from the brain surface who underwent surgery had an 8% absolute increase in good outcomes

– STICH II – 607 patients - primary outcome of the trial, measured as favorable outcome on the Extended Glasgow Outcome Scale, did not reach statistical significance

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• a subgroup analysis on the effect of baseline prognosis (poor versus good) identified an interaction, such that subjects in the poor prognosis group randomized to surgery were more likely to have a favorable outcome than those randomized to medical care

• Subjects who were judged in need of surgery were not enrolled.• 26% of subjects randomized to medical management ultimately

crossed over to surgery. In STICH II, 21% of subjects crossed over to surgery. These subjects were typically sicker, with lower GCS scores and larger hematomas.

• If none of these patients had undergone surgery, the rates of poor outcome and death in the medical group may have been higher

• minimally invasive hematoma drainage assisted by tissue plasminogen activator infusion; the Minimally Invasive Surgery plus rtPA for Intracerebral Hemorrhage Evacuation (MISTIE) I and MISTIE II trials have been completed, and a phase III trial is being organized

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• Advances in the management of intracerebral hemorrhage. Kuramatsu et al. J Neural Transm (2013) 120:S35–S41

– MISTIE II trial representing a minimally invasive access with a sequential parenchymal clot lysis using rtPA versus conservative management. demonstrated an increased rate (14 %) of functional independency at 1 year for treated patients, which, however, did not reach significance because of small patient numbers

– Spot sign is highly predictive of HE and has been reported to have a positive predictive value of 73%, a negative predictive value of 84%, sensitivity of 63%, and specificity of 90%.25 HE usually occurs in 30% of patients with ICH <3 hours of symptom onset,26 and the frequency of spot sign is highest in patients presenting <3 hours, but its accuracy in predicting HE remains high, regardless of time from symptom onset. (Neuroimaging in Intracerebral Hemorrhage. Stroke. 2014;45:903-908.)

– Promote recognition of a potential target population in HG prevention and all of these phase 2 studies, STOP-IT (NCT00810888), SPOTLIGHT (NCT01359202), and STOP-AUST (NCT01702636), corroborate invasive treatment approaches using either recombinant factor VII or tranexamic acid to assess its influence on the primary endpoint of HG.

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• Long-term prognosis after intracerebral haemorrhage: systematic review and meta-analysis. Poon MTC, et al. J Neurol Neurosurg Psychiatry 2014;85:660–667– This systematic review and meta-analysis of 122

longitudinal cohort studies reporting long-term (>30 days) outcome after spontaneous ‘primary’ ICH has shown that 1-year survival was 46.0% (figure 1) and 5-year survival was 29.2% (figure 2) in population-based studies.

– predictors of death in the long term were increasing age, decreasing Glasgow Coma Scale score, increasing ICH volume, presence of intraventricular haemorrhage and deep/infratentorial ICH location, which are the principal components of the ICH score

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• Less than a half of patients with ICH survive 1 year and less than a third survive 5 years. Risks of recurrent ICH and ischaemic stroke after ICH appear similar after ICH, provoking uncertainties about the use of antithrombotic drugs.

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In Sum• If you are going to bang your head, have an EDH not an ASDH• If you’re over 65 with an ASDH your chance of being able to look after yourself without help

is about 40% (but that’s only if you’re not in the 35% who die perioperatively)• So have your clot evacuated and your Warfarin reversed• If you have a CSDH and are over 90 years old, have it in Tokyo not New Mexico• Being a girl is still a slightly risky business for SAH - especially if you smoke, drink and have

high blood pressure• Oh and SDH from aneurysms btw• Have your aneurysm coiled if possible (unless you’ve had a subdural – then have it clipped

whilst you have your clot evacuated) and your vasospasm treated with hypertension – not lots of fluids

• Also have some magnesium• And if you’re pregnant try to have your SAH after 28 weeks so baby can be delivered – if not

clipping provides the better occlusion – but whichever you choose – have your aneurysm secured

• Try not to have an haemorrhagic stroke – and certainly not one with a spot sign on contrast CT

• If you do then have your clot evacuated if your prognosis is poor or if it’s in your post fossa• If your prognosis isn’t so awful – have some rTPA lysis rather than a craniotomy whilst you

have your BP controlled • And overall be managed in a centre that has experience at dealing with these things

(preferably in Tokyo!!)

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References• Age and Salvageability: Analysis of Outcome of Patients Older than 65 Years

Undergoing Craniotomy for Acute Traumatic Subdural Hematoma. Taussky, et al WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.10.030

• Aneurysmal acute subdural hemorrhage: Prognostic factors associated with treatment. Kulwin et al. Journal of Clinical Neuroscience 21 (2014) 1333–1336

• The current role of decompressive craniectomy in the management of neurological emergencies. Honeybul. Brain Inj, 2013; 27(9): 979–991

• Extradural haematoma—To evacuate or not? Revisiting treatment guidelines. Zakaria et al. Clinical Neurology and Neurosurgery 115 (2013) 1201–1205

• Glasgow Coma Scale on admission is correlated with postoperative Glasgow Outcome Scale in chronic subdural hematoma. Amirjamshidi et al. Journal of Clinical Neuroscience 14 (2007) 1240–1241

• Advances in the management of intracerebral hemorrhage. Kuramatsu et al. J Neural Transm (2013) 120:S35–S41

• Neuroimaging in Intracerebral Hemorrhage. Macellari et al. Stroke. 2014;45:903-908.)• Long-term prognosis after intracerebral haemorrhage: systematic review and meta-

analysis. Poon MTC, et al. J Neurol Neurosurg Psychiatry 2014;85:660–667• New Developments in the Treatment of Intracerebral Hemorrhage. Gomes. Neurol

Clin 31 (2013) 721–735

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References• Outcome of acute and chronic subdural hematomas in patient 90 years and older.

Stippler et al, 3.cns.org/dp/2012CNS/419.pdf• Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a

single-centre experience. Taussky et al, SWISS MED WKLY 20 08;138(19–20):281–285

• Subarachnoid Haemorrhage from Intracranial Aneurysms during Pregnancy and the Peurperium. Kataoka et al, Neurol Med Chir (Tokyo) 53,549-554. 2013

• Surgery for Intracerebral Hemorrhage Moving Forward or Making Circles? Flaherty. Stroke. 2013;44:2953-2954.

• Traumatic brain injury: intensive care management. Helmy et al. Br J Anaesth 2007; 99: 32–42

• Chronic Subdural Hematoma in Patients Over 90 Years Old in a Super-Aged Society. Tabuchi. J Clin Med Res. 2014;6(5):379-383

• Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Dankbaar et al. Critical Care 2010, 14:R23