The Guidelines
CTA or Not?
If admission site is the same is this really valuable?
CTV or Not?
In patients with lobar spontaneous ICH and age <70 years, deep/posterior fossa spontaneous ICH and age <45 years, or deep/posterior fossa and age 45 to 70 years without history of hypertension, acute CTA plus consideration of venography is recommended to exclude macrovascular causes or cerebral venous thrombosis
Blood Pressure Control
Studies had ridiculous time to bp control initiation
A subgroup analysis of ATACH-2 found that EIBPL within 2 hours of ICH onset was associated with lower risk of HE and improved 90-day outcomes compared with later
time points
In patients with spontaneous ICH requiring acute BP lowering, careful titration to ensure continuous smooth and sustained control of BP, avoiding peaks and large variability in SBP, can be beneficial for improving functional out comes
In patients with spontaneous ICH of mild to moderate severity presenting with SBP between 150 and 220 mm Hg, acute lowering of SBP to a target of 140 mm Hg with the goal of maintaining in the range of 130 to 150 mm Hg is safe and may be reasonable for improving functional outcomes
In patients with spontaneous ICH of mild to moderate severity presenting with SBP >150 mm Hg, acute lowering of SBP to <130 mm Hg is potentially harmful
Questions about BP Control in Large Strokes with obtundation re: risk/benefit of BP control prior to ICP monitoring
EMCrit Recs
- Use nicardipine as your 1st agent
- Get goal BP within 1 hr
- Place an aline if possible, put BP cuff at q10 minutes if you can't
Anticoagulation Reversal
In patients with anticoagulant-associated
spontaneous ICH, anticoagulation should be
discontinued immediately and rapid reversal of
anticoagulation should be performed as soon
as possible after diagnosis of spontaneous
ICH to improve survival
In patients with VKA-associated spontaneous
ICH and INR ≥2.0, 4-factor (4-F) prothrombin
complex concentrate (PCC) is recommended
in preference to fresh-frozen plasma (FFP)
to achieve rapid correction of INR and limit
HE.1
In patients with VKA-associated spontaneous
ICH with INR of 1.3 to 1.9, it may be reasonable
to use PCC to achieve rapid correction of
INR and limit HE
In patients with direct factor Xa inhibitor–associated
spontaneous ICH, andexanet alfa is
reasonable to reverse the anticoagulant effect
of factor Xa inhibitors
In patients with direct factor Xa inhibitor–
associated spontaneous ICH, a 4-F PCC or
activated PCC (aPCC) may be considered to
improve hemostasis.
When specific reversal agents are not available, aPCC or 4-F PCC may promote hemostasis in patients on direct thrombin inhibitors
See Also: EMCrit 319 – Safe and Smart Reversal of Anticoagulation / Anti-platelet Agents in 2022
PLTs
Plt transfusion only if thrombocytopenic or undergoing neurosurgical intervention
dDAVP for ASA, for Clopidogrel?
Who Should Get Transferred?
DVT Prophylaxis
In nonambulatory patients with spontaneous ICH, initiating low-dose UFH or LMWH prophylaxis at 24 to 48 hours from ICH onset may be reasonable to optimize the benefits of preventing thrombosis relative to the risk of HE.
Hematoma Evacuation
For patients with supratentorial ICH of >20- to
30-mL volume with GCS scores in the moderate
range (5–12), minimally invasive hematoma
evacuation with endoscopic or stereotactic
aspiration with or without thrombolytic use can
be useful to reduce mortality compared with
medical management alone.379–388
2b B-R
2. For patients with supratentorial ICH of >20-
to 30-mL volume with GCS scores in the
moderate range (5–12) being considered for
hematoma evacuation, it may be reasonable
to select minimally invasive hematoma evacuation
over conventional craniotomy to improve
functional outcomes.382,383,385–387,389,390
2b B-R
3. For patients with supratentorial ICH of >20-
to 30-mL volume with GCS scores in the
moderate range (5–12), the effectiveness of
minimally invasive hematoma evacuation with
endoscopic or stereotactic aspiration with or
without thrombolytic use to improve functional
outcomes is uncertain.379
Should IVH get transferred?
In patients with supratentorial ICH who are
deteriorating, craniotomy for hematoma evacuation
might be considered as a lifesaving
measure
For patients with cerebellar ICH who are
deteriorating neurologically, have brainstem
compression and/or hydrocephalus from
ventricular obstruction, or have cerebellar ICH
volume ≥15 mL, immediate surgical removal of
the hemorrhage with or without EVD is recommended
in preference to medical management
alone to reduce mortality.
- In patients with supratentorial ICH who are in
a coma, have large hematomas with significant
midline shift, or have elevated ICP refractory
to medical management, decompressive craniectomy
with or without hematoma evacuation
may be considered to reduce mortality.453–460
2b C-LD - In patients with supratentorial ICH who are in
a coma, have large hematomas with significant
midline shift, or have elevated ICP refractory
to medical management, effectiveness of
decompressive craniectomy with or without
hematoma evacuation to improve functional
outcomes is uncertain.458–
Who gets ICP Monitoring and Other ICP Stuff
In patients with moderate to severe spontaneous ICH or IVH with a reduced level of consciousness, ICP monitoring and treatment might be considered to reduce mortality and improve outcomes
For fracks sake, stop the continuous hyperosmolar therapy
Who Gets Continuous EEG?
Should any sICH (not aSAH) receive Anti-Seizure Proph in the absence of Seizures?
Limitation of Life-Sustaining Treatments
Talk about Casey's tweetorial on predication scores
Casey's Write-Up on the Guidelines
Update on the Management of sICH
Big picture
ICH although a less frequent cause of stroke is associated with a high mortality (30-40%) and disproportionately effects Black and Mexican Americans than white Americans and we have not seen a significant reduction in mortality or morbidity from this disease.
What is changing is our understanding of the underlying pathophysiology and how to better understand the long term hemorrhage risk in these complex patients, especially those with CAA.
Reading the guidelines emphasizes there are so many basic aspects of management we still don’t have great evidence to best practice.
What’s meant by spontaneous ICH?
- Intracerebral hemorrhage can be thought of in 4 buckets
- Trauma
- Other secondary causes of hemorrhage: Hemorrhagic mets, hemorrhagic conversion of ischemic pathology, venous pathology,
- Macrovascular diseases: AVMs, aneurysms
- Microvascular disease: Historically this has been the pathology that has been defined as “primary ICH,” but we now have a much better understanding that what appears spontaneous is precipitated by pathologic small vessel remodeling and breakdown
- Arteriolosclerosis / lipohyliosis (“HTN-hemorrhage”) vs Cerebral Amyloid Angiopathy (CAA)
- Each has a signature location of occurring in the brain.
What’s new in this guideline?
- An emphasis on understanding the underlying etiology of spontaneous ICH, even in patients who have not had a primary ICH
- Emphasis on 3 tiers of care
- Emergency and acute care
- Inpatient care
- Recovery: stroke prevent and rehabilitation
New/Important within Emergency and acute care:
- The acute care goal is to: Prevent the widespread injury caused by ICP, hydrocephalus, herniation, reverse a/c, control BP and transfer to the appropriate facility.
- Early triage and early evaluation, which are improved by EMS prenotification (44)
- Severe ischemic strokes benefit from early triage to the nearest comprehensive stroke center… But, we do not know if the same is true for ICH, but MSU may be beneficial to ICH in that BP management will begin earlier (46) … although we don’t know yet if ultra-early BP lowering is beneficial
- Limit hematoma expansion and know who is most at risk: how to use imaging to risk stratify
- CTA with the spot sign helpful in figuring out who is at highest risk for hemorrhage expansion (also will rule out macrovascular pathology), but there are also signs just on the NCHCT – like mixed density
- Further etiology investigation is critical in patients with lobar hemorrhages < 70, or deep hemorrhages <45 yo or deep hemorrhages 45-70 yo without a history of HTN (diagnostic yield of a CTA was 17% DIAGRAM) (118)
- and may prevent radiographically notable HE (220,221, 230)
- BP lowering
- BP lowering is still largely informed by INTERACT2 and ATACH2, avoid large fluctuations, start ASAP (although we don’t have any evidence that supports ultra-early BP lowering). These trials suggest <140mmHg may be reasonable without increasing SAE.
- Think about your patient population though – boxing kidneys is also bad and AKI contributes to poor outcomes
- In patients with large bleeds and increased ICP, acute BP lowering should keep in mind the elevated ICP will put the patient at risk of dropping their CPP
- Management of a/c reversal
- General hemostasis stuff:
- Still don’t know enough to say if there are some groups that might benefit from TXA, DDAVP. TXA may limit HE, but in the phase 2 trials in patients that would have seemed to be at highest risk of HE, it didn’t have any effect on death or functional outcomes, continues to be shown to be safe On Warfarin? 4F-PCC is better than FFP (163) + Vitamin K
- “Reversal of the anticoagulant effect of direct thrombin inhibitors and factor Xa inhibitors can be performed rapidly with specific reversal agents (idarucizumab168 and andexanet alfa,166 respectively).However, there are few clinical data on the effectiveness of these agents in preventing HE or improving functional outcomes, and in real-world situations, clinicians will have to balance the expense against the benefit of these drugs. When specific reversal agents are not available, aPCC or 4-F PCC may promote hemostasis in patients on direct thrombin inhibitors.” (176)
- We have Andexanet, but I have never preferentially given this, thoughts from you guys? In the couple cases I’ve dealt with that got AA, we had to worry about the rebound effect and it just was more of a headache. I worry now about the guidelines having a stronger recommendation for using this over 4F PCC that we’ll be more compelled to follow the guidelines and give AA…
- Another point about the reversal chart of page 20 uses weight based dosing for 4F-PCC, I have moved to given fixed dosing if patient is known to be compliant, and then checking and INR 30 mins later, and giving the rest of the weight based dose if INR> 1.4 … below the figure the text agrees with not waiting for the INR to be back, which has been my practice.
- General hemostasis stuff:
- Control of ICP:
- We don’t know how frequently patients have elevated ICPs (ie need to use clinical judgement from the exam most of the time)
- Bolus is likely to give a better response than continuous hyperosmolar therapies
- No evidence to support the prophylactic use – don’t set a random sodium goal
- Efficacy of hyperosmolar therapy is not well established, but reasonable
- Hypertonic saline may be better than mannitol
- Get the patient to a location were multi-disciplinary specialized care, get the NSG team on board
- Imperative in patients with ICH volume > 30cc, IVH, hydrocephalus or infratentorial bleeds (233, 234, 254)
- Guidelines emphasize that limitations in life-sustaining treatments do not necessarily mean comfort care only…
- Retrospective studies that predict low to no occurrence of readmission to an ICU after initial admission to a stroke unit or step-down unit.249–251 Criteria include low ICH volume (<20 mL), low NIHSS score (≤10), high GCS score (≥13), minimal or no IVH, and absence of uncontrolled BP and respiratory failure.
- Patients with moderate to severe supratentorial ICH (identified in most studies by volume ≥30 mL or GCS score <8) may benefit from neurosurgical evaluation.
- Scoring and GOC
- The ICH Score is helpful for conveying disease severity but should not be used in isolation to make decisions about life sustaining treatment. Clinician subjective judgement is more accurate than a score, and scores heavily influence a self-fulling prophecy. Most patients die by WLST
- 2a recommendation to postponement of new DNR / withdrawal of care until the second full day
- The optimal trial of aggressive care is unknown, [and probably dependents significantly on the patient’s admission frailty]
- DNR shouldn’t mean don’t do anything else
- Acute Surgical management
- Level 1 evidence for IVH and hydrocephalus with decreased consciousness à Drain
- Can consider ICP monitoring in patients with GCS<=8, not great evidence this is extrapolated from TBI mostly
- Not every 20-30cc and moderate GCS 5-12 should be considered for surgery and we don’t have evidence to support one group that best benefits from evacuation. We don’t know how early to intervene for hemorrhage evacuation. Whether to crani vs MIS has level 2b to consider the MIS approach. A network meta-analysis suggests stereotactic aspiration, endoscopy, craniotomy and last standard medical care for best outcome in these situations
Additional New Information
More on EMCrit
Additional Resources
- EMCrit Wee – Zentensivism with Matt Siuba - March 15, 2024
- EMCrit 370 – Extracorporeal Therapies for Toxicology & Poisoning #ExTRIP #NephMadness - March 8, 2024
- RACC Lit Review – Feb 2024 - February 28, 2024