Complication Of Intracerebral Hemorrhage Research Articles

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults

Purpose— The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. Methods— A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time. Results— Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined. (Stroke. 2007;38:2001-2023.)

Interhemispheric transcorpus callosal approach in the treatment of ventricular hemorrhage with obstructive hydrocephalus

Background Intraventricular hemorrhage, a frequent complication of intracerebral supratentorial hemorrhage, is associated with high rates of morbidity and mortality. Several methods have recently been developed for accelerating the clearance of intraventricular blood clots, especially during massive IVH. The present study was conducted to evaluate the interhemispheric, transcorpus callosal approach with septostomy for the management of supratentorial hemorrhage with intraventricular extension. Methods Eighteen patients with primary IVH or thalamic/caudate hemorrhage complicated by IVH received an operation for removal of intraventricular blood clots by the interhemispheric, transcorpus callosal approach with septostomy. All patients received a brain CT examination before and after surgery. Clinical outcomes were assessed 6 months after surgery by the GOS. Results Good clinical outcomes (GOS scores ≥4) were achieved in 45.6% of patients. In the patients with poor clinical outcome, the mean age was older ( P = .001) and diabetes mellitus was more common ( P = .04). Patients with thalamic hemorrhage with rupture into the third ventricle had worse clinical outcomes ( P = .04). The overall mortality rate at 6 months postsurgery was 5.6%. Conclusion The interhemispheric, transcorpus callosal approach with septostomy is safe and effective for direct removal of intraventricular blood clots during treatment of supratentorial hemorrhage with intraventricular extension. Further investigations involving more cases are needed to assess more fully the extent of improvement in clinical outcome attributable to this approach.

Secondary sclerosing cholangitis after long-term treatment in an Intensive care unit: clinical presentation, endoscopic findings, treatment, and follow-up

We present ten patients who developed secondary sclerosing cholangitis following long-term treatment in an intensive care unit (ICU) between 1999 and 2004. Ten consecutive patients who had no evidence suggestive of pre-existing hepatobiliary disease were admitted to an ICU because of trauma (n = 5), intracerebral hemorrhage (n = 3), or nonabdominal postsurgical complications (n = 2). All the patients had required treatment with long-term ventilation, catecholamines, total parenteral nutrition, and several antimicrobial agents. Cholestasis was first noted within 11 days after the initial insult. Endoscopic retrograde cholangiopancreatography (ERCP), performed after a median follow-up of 69 days, revealed multifocal stricturing and beading of the intrahepatic bile ducts, and attenuation of the peripheral branches. In all the patients, the bile ducts were partially filled by black-pigmented thrombotic material. All the patients underwent endotherapy, which comprised sphincterotomy and removal of the occluding material, in an attempt to improve biliary drainage; the treatment had to be repeated in seven of the ten patients. After a median follow-up period of 21 months, despite transient clinical improvement following endotherapy, complete recovery has not been achieved in any of the patients and so far one patient has had to undergo orthotopic liver transplantation as a result of end-stage liver disease. The development of secondary sclerosing cholangitis in patients who have received long-term treatment in an ICU is a rare event of unknown pathophysiology, but patients demonstrate characteristic findings on ERCP. It is not known whether endotherapy can delay the progress of the condition in the long term.

Intraventricular Hemorrhage: Presentation and Management Options

Intraventricular hemorrhage (IVH) as a primary event or as a complication of intracerebral hemorrhage (ICH) carries a poor prognosis. The effects of IVH on brain function are mediated via complicating hydrocephalus (with increased intracranial pressure and decreased cerebral perfusion pressure), presence of blood clots in the ventricular system, and carrying of blood degradation products into the CSF pathways, all of which contribute to morbidity and mortality. The management of IVH has been traditionally based on draining the blood from the ventricular system (and reducing hydrocephalus) via external ventricular drainage techniques. Their inadequate results (due to frequent obstruction of the draining system by clot) and tendency to complications (mainly infection) has led to the search of alternative treatments. A promosing approach has been the addition of intraventricular instillation of thrombolytics to the external ventricular drainage, in an attempt at accelerating blood clot lysis and removal. This approach has shown initial encouraging results, with adequate drainage of intraventricular clots without an increase in intracranial bleeding. The procedure is currently being tested in a prospective randomized clinical trial.

The STICH Trial

Section Editors: Marc Fisher MD Antoni Davalos MD Until the present, intracerebral hemorrhage (ICH) has been the stroke subtype that has defied attempts to find a scientifically proven effective therapy. Possible treatments of acute ICH include: (1) slowing or stopping of the bleeding during the first several hours after onset or (2) removal of the accumulated hematoma to prevent the mechanical complications of mass effect as well as the toxic effects of blood on the surrounding brain parenchyma. Critical care management of the complications of ICH is clearly important. The evolution of lesions and the pathophysiology of intracerebral hemorrhage, like that of ischemic stroke, are time-dependent,1,2⇓ but only the recently published trials of Novo VII have tried to intervene during the first hours after onset of ICH.3,4⇓ The recent publication of the Novo VII phase II trial also provides hope that an effective treatment for acute ICH is within reach. The STICH Trial represents an important milestone in the role of surgical treatment for ICH.5 The relative paucity of data from randomized trials has severely limited progress in the surgical treatment of ICH and has led to substantial variability in the management of ICH throughout the world. Dr Mendelow, collaborators, and the Medical Research Council (MRC) are to be congratulated for completing the largest ever randomized treatment trial of ICH. This trial adds substantially to what we know about surgical management of ICH and will have an impact on current treatment as well as design of future trials. The goal of the STICH Trial was to investigate the effectiveness of early surgery (within …

Prediction of hospital disposition after thrombolysis for acute ischemic stroke using the National Institutes of Health Stroke Scale.

Early determination of discharge destination after acute stroke may promote earlier rehabilitation and reduce costs by shortening the duration of hospitalization. To determine whether the National Institutes of Health Stroke Scale (NIHSS) score predicts disposition in stroke patients treated with thrombolysis. Cohort study. Academic and community hospitals from 3 countries. Five hundred forty-six patients with acute ischemic stroke treated with recombinant tissue plasminogen activator (rt-PA). Medical records were reviewed for demographic information, vascular risk factors, location of stroke, initial NIHSS score, acute hospital disposition, and complications of symptomatic or asymptomatic intracerebral hemorrhage (ICH). Discharge destination to home, acute rehabilitation, or nursing facility. In multinomial regression analysis, increasing NIHSS score was a robust and independent predictor of discharge to rehabilitation or nursing facilities, roughly doubling for each 5-point increment. Patients who developed symptomatic ICH were never discharged to home, but asymptomatic ICH had no significant independent effect on disposition. Stroke severity as determined by the admission NIHSS score is the major independent predictor of disposition after hospitalization and treatment with rt-PA for acute stroke in a broad-based population. However, symptomatic ICH after rt-PA is a catastrophic event that may preclude discharge to home.

Transcranial color-coded duplex sonography in cerebral arteriovenous malformations.

It is well known that significant changes in cerebral hemodynamics may occur during the treatment of cerebral arteriovenous malformations with the complication of intracerebral hemorrhage and parenchymal edema. We used transcranial color-coded duplex sonography to study alterations in blood flow velocities during staged embolization. Forty-one patients aged 40 +/- 13 years (mean +/- SD) with angiographically proven cerebral arteriovenous malformations were studied. The blood flow velocities of the anterior, middle, and posterior cerebral arteries were measured in 16 patients with supratentorial arteriovenous malformations, both before the first and then after each successive embolization (three to seven treatments). In 29 of 41 patients (71%), transcranial color-coded duplex sonography satisfactorily revealed the malformations and their main feeders. After the final embolization, we found a reduction in the peak flow velocity in treated feeders of 23 +/- 28% compared with the values before the first embolization. The untreated feeders showed an increase in peak flow velocities of 12 +/- 23% as an expression of increased collateral flow. After the treatment of the supplying feeders, we observed a reduction in flow velocity of 25 +/- 13% in seven patients, with cross-filling of the arteriovenous malformation through the contralateral anterior cerebral artery and the anterior communicating artery. The technical advantage of transcranial color-coded duplex sonography compared with transcranial Doppler sonography is that it allows the exact identification of different feeding arteries in arteriovenous malformations. Repeated measurements during stepwise embolization with corrected insonation angle are easily achieved, and noninvasive quantification of hemodynamic changes is possible. The method may be helpful in the planning of the different steps of embolization.

Overview on thrombolysis in acute ischemic stroke

Objective : to give an overview of the literature on thrombolytic therapy in acute ischemic stroke within the last decade. Inclusion criteria for the studies were that the patients had CT scan done before inclusion and that thrombolytic therapy was started within 48 h of stroke onset. Design : the studies are grouped into those of intra-arterial administration of thrombolytic agents, in which recanalization is documented by angiography, and into those of intravenous administration, which studies may be angiography-based or symptom-based; in the latter case the degree of reperfusion is unknown. Results : in basilar artery occlusion intra-arterial thrombolytic therapy in 111 patients resulted in a rate of recanalization of 60%, the acute mortality was 51%, and good clinical outcome was obtained in 28%. In 41 patients with occlusion of the internal carotid artery the rate of partial recanalization was 56%. The acute mortality was 22% and good clinical outcome was seen in 20%. In 106 patients with occlusion of the middle cerebral artery, which is the most common site of cerebrovascular occlusion, recanalization was obtained in 50%. The acute mortality was 17%, and good clinical outcome was obtained in 43%. Intravenous administration of thrombolytic agents in 203 patients with middle cerebral artery or internal carotid artery occlusions resulted in recanalization in 37%. Acute mortality was 15%, and good clinical outcome was obtained in 44%. In symptom-based studies, intravenous administration of thrombolytic agents was associated with 3 months mortality of 18%. Good clinical outcome was obtained in 43%. The occurrence of parenchymal cerebral hemorrhage ranged from 5% to 18%. Three randomized, placebo-controlled trials comprising 156 patients with carotid territory stroke showed similar rates of intracerebral hemorrhagic complications in thrombolytic treated and placebo treated groups. There was no significant difference in mortality. Good clinical outcome was seen more frequently in actively treated patients than in the controls. Comments : Patients in symptom-based studies may have less severe strokes than patients in angiography-based studies and comparisons between trials are not valid. Intra-arterial application of thrombolytic agents may result in higher recanalization rates than intravenous application. However, no direct comparison of the two treatment modalities has been made, and no placebo-controlled study has yet been performed of intra-arterial administration. The limited data on intravenous application seem to indicate that recanalization occurs more frequently than by spontaneous recanalization. Several large, placebo-controlled, randomized symptom-based studies of intravenous administration of thrombolytic agents are underway.

Differentiation between ischemic and hemorrhagic stroke by transcranial color-coded real-time sonography.

Transcranial color-coded real-time sonography was applied to 20 patients with ischemic stroke and 28 patients with spontaneous intracerebral hemorrhage. In all patients the sonographic diagnosis corresponded closely to cranial computed tomography findings. Recent hemorrhages were visualized as a hyperechodense mass. The high contrast to minor echodense adjacent parenchyma led to a clear sonographic distinction. Older clots were characterized by a continuous decrease of echodensity and subsequently were interspersed by hypoechodense zones. In the acute stage of ischemic infarction, the vessel occlusion (17/20) and collateral vascular supply (10/20) could be depicted in the color-B-mode in two perpendicular planes and further verified by the Doppler mode. Brain edema was not visualized. Although in the acute stage no change of echo texture was observed within the infarction, hyperechodense regions (7/11) could be observed in some patients during the time course. Complications of intracerebral hemorrhage and ischemic stroke, such as disturbance of cerebrospinal fluid circulation, midline shift, and compression of adjacent territories, were depicted by transcranial color-coded sonography. These preliminary results illustrate that transcranial color-coded real-time sonography may be helpful in the early noninvasive differential diagnosis as well as long-term follow-up in patients with cerebrovascular disorders.

THE SYNDROME OF PREECLAMPSIA

Preeclampsia has traditionally been viewed as one of several forms of hypertension complicating pregnancy. More recently, the multisystem nature of this unique gestational disorder has been emphasized. Pathophysiologic events, including abnormal placentation and heightened vascular reactivity, may occur weeks or months prior to clinical recognition of the disease. Although most frequently presenting as hypertension and proteinuria, hepatic (abdominal pain and elevation of transaminases) and hematologic (intravascular hemolysis and thrombocytopenia) involvement may be important features of the disease. Current theories suggest that multiorgan dysfunction may be caused by widespread vascular endothelial dysfunction, vasospasm, and variable activation of coagulation mechanisms. Pending delivery, which is the only definitive therapy for preeclampsia, maternal complications of intracerebral hemorrhage and eclampsia may be prevented with judicious use of antihypertensive medication (e.g., hydralazine) and magnesium sulfate, respectively. Finally, data from a number of small trials suggest that low-dose aspirin (60-100 mg/d) may reduce the incidence of preeclampsia in patients at high risk without adversely affecting the fetus or newborn; however, it is recommended that aspirin not be used as a routine prophylactic intervention until publication of results of several ongoing large multicenter trials, which will help to more fully clarify the benefits and risks of this approach.

Comparison Among Three Methods of Intracranial Pressure Recording

Fluid-coupled recording systems are the most popular method of recording intracranial pressure (ICP), but they can be prone to blockage and infection. A series of 378 recordings of ICP was analyzed to identify complications and cases in which recording had to be discontinued prematurely because of catheter blockage. Three different methods of ICP recording were used: a ventricular catheter, a Richmond screw, and a subdural catheter. Richmond screws became blocked more often (16%) than subdural catheters (2.7%) or ventricular catheters (2.5%). Complications of infection and intracerebral hemorrhage were observed mostly in the ventricular catheter patients. Of these three methods, a subdural catheter is the preferred method of recording ICP.

Appendicular tremor as a late complication of intracerebral hemorrhage

A 23-year-old woman without demonstrable risk factors for cerebral hemorrhage was admitted after the acute onset of hemiparesis of the left side. A computed tomography scan showed a small right thalamic hemorrhage. Cerebral angiography was normal, and she was managed conservatively. Three months after the original ictus the patient developed severe tremor on the left side. Angiography again revealed no abnormalities and the tremor was successfully treated with a stereotaxic thalamic lesion superimposed on the area of the hemorrhage. The patient's disease, its treatment, and the current knowledge of the anatomy and physiology of movement disorders are reviewed.

Torsade de Pointe Atypical Ventricular Tachycardia Complicating Subarachnoid Hemorrhage

We report the findings in a patient in whom prolongation of the Q-T interval and torsade de pointe ventricular tachycardia occurred as a complication of intracerebral and subarchnoid hemorrhage. The dysrhythmia did not recur after treatment with propranolol. Prolongation of the Q-T interval occurs frequently in patients with subarachnoid hemorrhage, causing a predisposition to torsade de pointe ventricular tachycardia. Propranolol, by blocking excessive sympathetic stimulation and shortening the Q-T interval, may be effective therapy for ventricular dysrhythmias associated with subarachnoid hemorrhage.

Intracerebral Hemorrhage, Acute Hydrocephalus, and Systemic Hypertension

Hydrocephalus occurred as an acute complication (within four hours) of intracerebral hemorrhage in a 10-year-old girl. Following the insertion of a catheter into the cerebral ventricles, it was possible to reduce systemic hypertension and to improve the neurological condition of the patient by intermittent ventricular drainage. On the fifth day following the apoplectic event, an arteriovenous malformation of the right thalamus was surgically clipped with a satisfactory result. The following points are emphasized: acute hydrocephalus is an important and possibly common complication of intracerebral hemorrhage; in the case reported, systemic blood pressure was found to rise and fall in direct response to a rise or fall in the intraventricular pressure; and ventricular drainage was found to be useful in reducing a number of immediate complications of intracerebral hemorrhage.