Management Of Acute Intracerebral Hemorrhage Research Articles

The Story of Intracerebral Hemorrhage: From Recalcitrant to Treatable Disease.

This invited special report is based on an award presentation at the World Stroke Organization/European Stroke Organization Conference in November of 2020 outlining progress in the acute management of intracerebral hemorrhage (ICH) over the past 35 years. ICH is the second most common and the deadliest type of stroke for which there is no scientifically proven medical or surgical treatment. Prospective studies from the 1990s onward have demonstrated that most growth of spontaneous ICH occurs within the first 2 to 3 hours and that growth of ICH and resulting volumes of ICH and intraventricular hemorrhage are modifiable factors that can improve outcome. Trials focusing on early treatment of elevated blood pressure have suggested a target systolic blood pressure of 140 mm Hg, but none of the trials were positive by their primary end point. Hemostatic agents to decrease bleeding in spontaneous ICH have included desmopressin, tranexamic acid, and rFVIIa (recombinant factor VIIa) without clear benefit, and platelet infusions which were associated with harm. Hemostatic agents delivered within the first several hours have the greatest impact on growth of ICH and potentially on outcome. No large Phase III surgical ICH trial has been positive by primary end point, but pooled analyses suggest that earlier ICH removal is more likely to be beneficial. Recent trials emphasize maximization of clot removal and minimizing brain injury from the surgical approach. The future of ICH therapy must focus on delivery of medical and surgical therapies as soon as possible if we are to improve outcomes.

Effect of Race-Ethnicity and CT Angiography on Renal Injury During Blood Pressure Treatment for Intracerebral Hemorrhage.

Lowering blood pressure intensively in acute intracerebral hemorrhage (ICH) is associated with adverse renal events; Blacks and Hispanics have a higher incidence of ICH and kidney disease than Whites. In addition, CT angiography (CTA), which may also be associated with acute kidney injury (AKI), is often done in acute ICH. Our objective was to investigate the relationship between aggressive BP management, CTA, race-ethnicity and the risk of developing AKI in patients presenting with ICH. We retrospectively calculated the difference between the highest and lowest systolic blood pressure during the first 24h of admission in patients with spontaneous ICH over 30months. Creatinine (Cr) levels at admission were compared to the highest Cr level during the first 7days after admission. AKI was defined as any > 50% increase of baseline Cr during the first 7days. Logistic regression models were used to assess the association between race-ethnicity and CTA and AKI. We also analyzed the incidence of AKI stratified by race-ethnicity. A total of 394 patients were included (mean age ± SD 63 ± 14years), 160 patients (41%) were women, 162 (41%) Hispanic, 39 (10%) White and 189 (48%) Black. Most of the patients underwent CTA (73%). The prevalence of AKI was (18%), but no difference was found in AKI incidence (19% in Blacks vs. 17% in Whites vs. 18% in Hispanics (p = 0.940). In fully adjusted models, AKI was not associated with race-ethnicity (p = 0.665) or CTA (p = 0.187). The stratified analysis by race-ethnicity did not change our findings. We found no association between race-ethnicity or CTA and AKI during the acute management of ICH in a real-life stroke population. Our findings suggest that CTA can be safely obtained in acute ICH, even in populations of diverse race-ethnicity who may be more prone to adverse kidney events. CTA did not contribute to developing AKI.

Minimally invasive approaches for the evacuation of intracerebral hemorrhage: a systematic review.

Intracerebral hemorrhage (ICH) is associated with a high rate of morbidity and mortality. Minimally-invasive surgery (MIS) has been increasingly used in recent years. We systematically reviewed the role of MIS in the acute management of ICH using various techniques. A comprehensive electronic search for relevant articles was conducted on several relevant international databases, including PUBMED (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL). Our primary literature research resulted in 1134 articles. In total, 116 publications finally met the eligibility criteria to be included in our systematic review. Five major MIS categories for the evacuation of ICH were identified, respectively: minimally invasive direct aspiration with or without thrombolytics, endoscope assisted technique, sonothrombolysis, aspiration-irrigation device and endoport-assisted evacuation. The role of minimally invasive techniques in the management of ICH remains under dispute. However, a mounting evidence in the literature demonstrates that MIS is associated with significantly improved outcomes when compared with conservative treatment and conventional surgical evacuation strategy.

Temporal trends in early case-fatality rates in patients with intracerebral hemorrhage.

To assess whether temporal trends in very early (within 48 hours) case-fatality rates may differ from those occurring between 48 hours and 30 days in patients with spontaneous intracerebral hemorrhage (ICH). All cases of ICH that occurred in Dijon, France (151,000 inhabitants), were prospectively collected between 1985 and 2011, using a population-based registry. Time trends in 30-day case fatality were analyzed in 3 periods: 1985-1993, 1994-2002, and 2003-2011. Cox regression models were used to evaluate associations between time periods and case fatality within 48 hours and between 48 hours and 30 days, after adjustments for demographics, risk factors, severity, and ICH location. A total of 531 ICH cases were recorded (mean age 72.9 ± 15.8, 52.7% women). Thirty-day case fatality gradually decreased with time from 40.9% in 1985-1993 to 33.5% 1994-2002 and to 29.6% in 2003-2011 (adjusted hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.47-1.07, p = 0.106, for 1994-2002, and adjusted HR 0.49, 95% CI 0.32-0.73, p < 0.001, for 2003-2011). Over the whole study period, 43.6% of 1-month deaths occurred within the first 48 hours following ICH onset. There was no temporal change in case fatality occurring within the first 48 hours but a decrease in deaths occurring between 48 hours and 30 days was observed with time (HR 0.53, 95% CI 0.31-0.90, p = 0.02, for 1994-2002, and HR 0.32, 95% CI 0.32-0.55, p < 0.01, for 2003-2011, compared with 1985-1993). Although 30-day case fatality significantly decreased over the last 27 years, additional improvements in acute management of ICH are needed since very early case-fatality rates (within 48 hours) did not improve.

Reducing Cost and Intravenous Duration of Nicardipine in Intracerebral Hemorrhage Patients via an Interdisciplinary Approach

The mainstay of acute management of intracerebral hemorrhage (ICH) is blood pressure reduction. Intravenous (IV) nicardipine is an effective but costly intervention for blood pressure reduction in the intensive care unit (ICU). Earlier transition to oral (PO) antihypertensive agents may reduce ICU length of stay (LOS) and associated costs. We sought to study the effectiveness of an interdisciplinary intervention to start earlier transition to PO antihypertensives. From July 2011 to July 2012, patients with ICH who received IV nicardipine were reviewed and screened for eligibility by an interdisciplinary team including physicians and pharmacists. These patients were compared to a control group 1 year prior to this intervention. The duration of nicardipine treatment (median hours), estimated costs, and ICU LOS were measured. A total of 35 patients and 44 controls were studied. The median hours of IV nicardipine use were significantly decreased from a baseline mean of 118 to 30 hours (P < .001); total cost savings per year was $433,566 ($18,475 per patient). The average LOS remained similar (8.4 versus 8.9 days, P < .990). In a follow-up study 1 year later, after the intervention was no longer used, a sample of 21 consecutive patients was reviewed and the duration of IV nicardipine treatment had increased to a mean of 96 hours. A physician and pharmacist-led project to initiate oral antihyperintensive medications earlier was successful in reducing the duration of IV nicardipine treatment in patients with ICH while leading to substantial cost savings.

What are the next breakthroughs in the management of acute intracerebral hemorrhage?

The impact of acute therapy for intracerebral hemorrhage is far behind that for acute ischemic stroke. Potential breakthroughs in the management of acute intracerebral hemorrhage are presented. To prevent early hematoma growth, acute blood pressure lowering, emergent hemostatic therapy, and minimally invasive surgery with topical thrombolysis have been attempted. Anti-inflammatory and neuroprotective pharmacotherapies may attenuate perihematomal edema as a surrogate marker for the inflammatory response and improve clinical outcomes after intracerebral hemorrhage. Hyperacute modification of vital parameters, early seizure control, early rehabilitation, and neuroregenerative therapy are other promising strategies in the foreseeable future.

Management of acute intracerebral hemorrhage – when to start and how to treat

Management of acute intracerebral hemorrhage – when to start and how to treat

One-stop multi-mode computed tomography in the diagnosis and management of acute intracerebral hemorrhage

多模式CT包括平扫CT、CT血管造影(CTA)以及CT灌注成像(CTP).目前北京天坛医院对脑出血患者进行一站式多模式CT项目检查(图1),在CTA预测早期血肿扩大、平扫CT获得“相对增容比”预测脑疝风险、CTP-PS(CTP -毛细血管通透性)评价血脑屏障破坏等方面获得了一些研究数据。

Abstract 3326: Reliability Of Hematoma Volume Calculation At Local Sites In The Setting Of A Multicenter Intracerebral Hemorrhage Clinical Trial

Background: In the clinical trials evaluating new therapies for acute management of intracerebral hemorrhage (ICH), rapid hematoma volume (HV) measurements from computed tomographic (CT) scan using previously described ‘ABC/2’ method at study sites is frequently required for either determining eligibility or stratification. However, the accuracy of this method by multiple observers using variable visual display modes is not known. Method: We performed a post hoc analysis of a multicenter clinical trial that recruited ICH patients within 6 hours of symptom onset at ten sites in the United States. HV was measured by local site investigators to determine eligibility for enrollment (&lt;60 cc) into the trial using the ABC/2 method (manual method) on the initial CT scan. CT scan images were subsequently sent to the core imaging laboratory for blinded computer based analysis of HV using ‘Medical Image Processing, Analysis, and Visualization (MIPAV)’ software (computer method). Paired t-test was used to identify any differences between the manual and the computer methods of HV measurements. Spearman’s correlation was used to study the agreement between the two methods. Results: HV measurements by both the manual and the computer methods were available in 51 patients enrolled in the trial (mean±standard deviation [SD] age 62±15 years; 26 were women.) The mean±SD HV using as calculated by he computer method (14.6±15.3 mL) was not statistically different from the values calculated by the manual method (16.5±15 mL; p=0.6). Using Spearman’s correlation, there was a significant correlation between the two methods (rho 75%, p&lt;0.01). Manual calculation under estimated the HV by an average of 1.5 mL in the lower 50 percentile of computer-calculated HV (&lt;9.4 ml), while overestimated the HV in the upper 50 percentile by an average of 3.1 mL. None of these differences were statistically significant. Conclusion: Rapid measurements at study sites for either determining eligibility or stratification provides reliable HV measurements despite measurements by multiple observers using variable visual CT scan display modes.

The Acute Management of Intracerebral Hemorrhage

The Acute Management of Intracerebral Hemorrhage

The Acute Management of Intracerebral Hemorrhage: A Clinical Review

The Acute Management of Intracerebral Hemorrhage: A Clinical Review

The Acute Management of Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a devastating disease with high rates of mortality and morbidity. The major risk factors for ICH include chronic arterial hypertension and oral anticoagulation. After the initial hemorrhage, hematoma expansion and perihematoma edema result in secondary brain damage and worsened outcome. A rapid onset of focal neurological deficit with clinical signs of increased intracranial pressure is strongly suggestive of a diagnosis of ICH, although cranial imaging is required to differentiate it from ischemic stroke. ICH is a medical emergency and initial management should focus on urgent stabilization of cardiorespiratory variables and treatment of intracranial complications. More than 90% of patients present with acute hypertension, and there is some evidence that acute arterial blood pressure reduction is safe and associated with slowed hematoma growth and reduced risk of early neurological deterioration. However, early optimism that outcome might be improved by the early administration of recombinant factor VIIa (rFVIIa) has not been substantiated by a large phase III study. ICH is the most feared complication of warfarin anticoagulation, and the need to arrest intracranial bleeding outweighs all other considerations. Treatment options for warfarin reversal include vitamin K, fresh frozen plasma, prothrombin complex concentrates, and rFVIIa. There is no evidence to guide the specific management of antiplatelet therapy-related ICH. With the exceptions of placement of a ventricular drain in patients with hydrocephalus and evacuation of a large posterior fossa hematoma, the timing and nature of other neurosurgical interventions is also controversial. There is substantial evidence that management of patients with ICH in a specialist neurointensive care unit, where treatment is directed toward monitoring and managing cardiorespiratory variables and intracranial pressure, is associated with improved outcomes. Attention must be given to fluid and glycemic management, minimizing the risk of ventilator-acquired pneumonia, fever control, provision of enteral nutrition, and thromboembolic prophylaxis. There is an increasing awareness that aggressive management in the acute phase can translate into improved outcomes after ICH.

Management of Acute Intracerebral Hemorrhage

Management of Acute Intracerebral Hemorrhage

Medical management of acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is the most serious but least treatable form of stroke, with prognosis critically dependent on both the size and degree of hematoma expansion. Treatments that target hematoma expansion offer potential to improve outcomes. This review analyzes the recent literature pertaining to the medical management of ICH. Modern imaging studies have confirmed the dynamic nature of ICH. At least one-third of patients experience significant continued bleeding and hematoma expansion in the first few hours after onset, more so in warfarin-related ICH. Despite a strong biological rationale for benefit, a large clinical trial of recombinant activated factor VII failed to show any treatment effects on substantive outcomes despite clear attenuation of hematoma growth. The impact of recombinant activated factor VII is therefore severely restricted because of uncertain efficacy, definite hazard, and high cost. Accumulating evidence indicates beneficial effects from the early normalization of international normalized ratio levels and replacement of coagulation factors in warfarin-related ICH. Although high blood pressure (BP) is common and associated with poor outcomes in ICH, there is insufficient evidence to recommend a specific early BP management strategy, although recent randomized evidence indicates that such treatment is well tolerated and readily incorporated into routine clinical practice. Definitive evidence to support a low-cost, widely applicable treatment is urgently required for a condition in which therapy is primarily supportive. In patients with acute ICH, rapid intensive BP-lowering treatment may provide protection against hematoma growth without concerns about safety and tolerability. How well such treatment can translate into overall benefits to patients is yet to be determined. At present, recombinant activated factor VII cannot be recommended for routine use, although BP lowering should generally follow conservative guidelines.

Timing Is Everything in Intracerebral Hemorrhage

To the Editor: Hallevi and coworkers recently reported on the off-label use of rFVIIa in 46 patients with ICH.1 Twenty-four patients received rFVIIa within 3 hours, and 22 within 3 to 4 hours. Volume increase and outcome at discharge were compared with 148 historical controls. The authors did not find a difference in reduction of volume increase between the 0 to 3 and the 3 to 4 hour group. Nor did they find a difference in outcome between the factor VIIa treated and the control patients. They conclude that timing of hemostatic therapy may not have an influence on volume reduction or outcome in ICH patients. We are not as quick to agree with this conclusion, for the following reasons: First, mean volumes were remarkably smaller—only one-third—than volumes that were found in FAST.2 Size of …

Recent advances in the management of acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is the most deadly form of stroke, and its acute treatment has suffered from a lack of guidance by reliable clinical trial data. In the past year, however, important clinical trials have helped point toward effective acute management. Studies have shown that magnetic resonance imaging is as accurate as computed tomography in diagnosing acute ICH, although this study is not always feasible in critically ill patients. Ultra-early hemostatic therapy has shown promise in limiting early hematoma expansion and rebleeding. The role of early surgery in patient management has been partially clarified. Finally, a novel treatment for intraventricular hemorrhage has shown promise in speeding clot resolution. All of these advances provide grounds for optimism that multimodal, evidence-based treatment of acute ICH will be reality in the near future.