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Section 3.7

Intracerebral Hemorrhage

NOTES on this recommendation

  • This recommendation is for patients with intracerebral hemorrhage. It applies to the initial assessment in the emergency department within the first few hours of patient arrival.
  •  Treatment and management of hemorrhagic stroke patients is outside the scope of these recommendations.


Patients with intracerebral hemorrhage must be treated as a medical emergency. Intracerebral hemorrhage should be promptly recognized and patients evaluated immediately by physicians with expertise in stroke management [Evidence Level A].

  1. Evaluation of patients with acute intracerebral hemorrhage should include questions about anticoagulant therapy, measurement of platelet count, partial thromboplastin time (PTT) and International Normalized Ratio (INR) [Evidence Level A].
  2. Patients with suspected intracerebral hemorrhage should undergo a CT or MRI immediately to confirm diagnosis, location and extent of hemorrhage [Evidence Level A].
  3. Patients with acute intracerebral hemorrhage and an established coagulopathy or a history of anti-coagulant use should be treated appropriately to reverse the coagulopathy (prothrombin complex concentrate, Vitamin K, or fresh-frozen plasma [Evidence Level B].
    1. If there is a persisting strong indication for anticoagulation (e.g. mechanical heart valve), the decision about when to restart anticoagulant therapy should be made on a case-by-case basis [Evidence Level C].
  4. Administration of recombinant Factor VIIa (NiaStase®) prevents hematoma growth, but increases the risk of arterial thromboembolic phenomena and does not provide a clinical benefit for survival or outcome. It is not recommended for routine use (FAST trial) 254[Evidence Level A].
  5. Patients with cerebellar hemorrhage should be referred for urgent neurosurgical consultation and consideration of evacuation of intracerebral hemorrhage particularly in the setting of altered level of consciousness or new cranial neuropathy [Evidence Level B].
  6. Patients with acute intracerebral hemorrhage should be considered for CT angiography or other imaging modality to exclude an underlying lesion such as an aneurysm, arteriovenous malformation, or tumour [Evidence Level B].
  7. Medically stable patients with an acute intracerebral hemorrhage should be admitted to a Stroke Unit or neuro-intensive care unit [Evidence Level B], and undergo interprofessional stroke team assessment to determine their rehabilitation and other care needs (refer to Recommendation 5.1).
  8. No randomized trials provide specific targets for systolic or diastolic blood pressure in patients with intracerebral hemorrhage   at the time of publication of these recommendations [Evidence Level C]. Randomized trials are ongoing.
  9. A majority of patients with acute supratentorial ICH will not require neurosurgical evacuation of the hemorrhage. However, selected patients with acute supratentorial intracerebral hemorrhage may be considered for surgical intervention including placement of extraventricular drain (EVD) for treatment of hydrocephalus, or craniotomy for evacuation of superficial lobar intracerebral hemorrhage [Evidence Level B].255
  10. Beyond the acutely symptomatic period, patients with intracerebral hemorrhage should be managed similarly to those with ischemic stroke, except for avoidance of antithrombotics.
  11. Intracerebral hemorrhage should not be considered an indication for statin therapy [Evidence Level A]. 128 Continued use in patients previously on a statin for another appropriate indication should be reviewed following ICH because of a potential increased risk of recurrent hemorrhage. Currently, there is insufficient evidence to determine whether the potential increased risk of hemorrhage outweighs the potential benefits for prevention of ischemic cardiovascular disease in ICH survivors with other appropriate indications for statins.256
    Symptoms of Intracerebral Hemorrhage
    • Sudden onset of severe headache (sometimes described as "thunderclap headache") that patients will often characterize as the worst of their life.
    • The headache of SAH is usually associated with nausea, vomiting, meningismus and photophobia and can also be associated with altered level of consciousness.
    • Signs on physical examination vary depending on the location of the aneurysm and the extent of the hemorrhage as well as whether there is intraventricular of intracerebral extension of the subarachnoid hemorrhage. Physical signs can include diminished level of consciousness, cranial nerve palsy, hemiparesis and subhyaloid hemorrhage on fundoscopic exam, but it is important to note that patients with acute SAH often have a NORMAL neurological examination, so the absence of physical findings should not alter the index of suspicion raised by the clinical presentation.
    Rationale

    Intracerebral hemorrhage is a life-threatening emergency and requires prompt recognition and action. Intracerebral hemorrhage commonly occurs in about 12 to 15 percent of all stroke patients admitted to Canadian hospitals,85 and is associated with high rates of early mortality – 25 to 50 percent in the first 30 days.257 Patients who survive an intracerebral hemorrhage are often left with moderate to severe persistent functional deficits which place a significant burden on families and the healthcare system.

    System Implications
    • Timely access to diagnostic services such as neuro-imaging, with protocols for prioritizing potential stroke patients.
    • Timely access to specialized stroke care (i.e. a neuro-intensive care unit) and neurosurgical specialists for hemorrhagic patient management, including rapid referral process if neurosurgical services not available within the initial treating hospital.
    • Access to organized stroke care, ideally stroke units with a critical mass of trained staff and an interprofessional team.
    • Education for pre-hospital, emergency department, and hospital staff on the characteristics and urgency for management of intracerebral hemorrhage patients.
    Performance Measures
    1. Risk-adjusted mortality rates for intracerebral hemorrhage in-hospital, 30-day and one year (core).
    2. Percentage of intracerebral hemorrhage patients who receive a CT or MRI within one hour of hospital arrival.
    3. Percentage of intracerebral hemorrhage patients who require surgical intervention.
    4. Percentage of intracerebral hemorrhage patients who experience intraoperative complications and mortality during surgery for intracerebral hemorrhage.
    5. Distribution of functional ability measured by standardized functional outcome tools at time of discharge from hospital.

    Measurement Notes:

    • Mortality rates should be risk-adjusted for age, gender, stroke severity and comorbidities
    • Time interval measurements should start from symptom onset of known or from triage time in the emergency department as appropriate.
    Implementation Resources and Knowledge Transfer Tools
    Summary of the Evidence

    Intracerebral hemorrhage (ICH) is a devastating emergency situation that requires rapid recognition, assessment and management. Presentation differs from ischemic stroke and subarachnoid hemorrhage in that the sudden focal neurological deficits may progress over a few minutes to a few hours and vomiting is more common in ICH than in SAH, as is changes in level of consciousness.10, 258 Risk factors for ICH appeared to be age, male sex, hypertension, and high alcohol intake. A systematic review of risk factors for ICH found in cohort studies the crude RR for age (every 10-year increase) was 1.97 (95% confidence interval [CI], 1.79 to 2.16). 259 In case-control studies, the crude OR for high alcohol intake was 3.36 (95% CI, 2.21 to 5.12) and for hypertension was 3.68 (95% CI, 2.52 to 5.38). Two cohort studies showed an increasing risk of ICH with increasing degree of hypertension. In cohort and case-control studies combined, the crude RR for sex (male versus female) was 3.73 (95% CI, 3.28 to 4.25); for current smoking, 1.31 (95% CI, 1.09 to 1.58); and for diabetes, 1.30 (95% CI, 1.02 to 1.67).

    In a retrospective chart audit, Hill and colleagues (2000) identified 423 index patients with primary ICH (PICH). 257 Of these, 27.4 percent died in the first 30 days of their admission. Predictors of death were reported as age, intraventricular rupture of hemorrhage, and trilobar hemorrhage. The recurrence rate for PICH was 2.4 percent (95% CI 1.4% to 3.9%) per year, whereas the recurrence rate for ischemic cerebrovascular disease was 3.0% (95% CI 1.8% to 4.7%) per year. The only significant predictor of readmission for ICH was lobar location of the index hemorrhage, with a hazard ratio of 3.8 (95% CI 1.2 to 12.0).

     

    Several debates have been published regarding the sensitivity of MRI versus CT scans for detection of ICH. A recent Cochrane review (2009) compared the diagnostic accuracy of diffusion-weighted MRI (DWI) and CT for acute ischaemic stroke, and to estimate the diagnostic accuracy of MRI for acute hemorrhagic stroke.260 Of the eight studies included in the analysis, two studies addressed hemorrhagic stroke patients. Their findings were that the two studies on hemorrhagic stroke reported high estimates for diffusion-weighted and gradient-echo sequences but had inconsistent reference standards. Chalela and colleagues conducted a single-centre, prospective, blind comparison of non-contrast CT and MRI (with diffusion-weighted and susceptibility weighted images) in a consecutive series of patients referred for emergency assessment of suspected acute stroke.261 A total of 356 patients were assessed independently by four experts blinded to clinical details. The results found MRI similar to CT for the detection of acute intracranial hemorrhage. MRI detected acute ischaemic stroke in 164 of 356 patients (46%; 95% CI 41-51%), compared with CT in 35 of 356 patients (10%; 7-14%). In the subset of patients scanned within 3 h of symptom onset, MRI detected acute ischaemic stroke in 41 of 90 patients (46%; 35-56%); CT in 6 of 90 (7%; 3-14%). Relative to the final clinical diagnosis, MRI had a sensitivity of 83 percent (181of 217; 78-88%) and CT of 26 percent (56 of 217; 20-32%) for the diagnosis of any acute stroke.

    Kidwell conducted a prospective study in two USA acute hospitals which compared CT scan to MRI for acute ICH.262 The study was stopped when an interim analysis, completed after the first 200 patients were enrolled, showed that MRI was detecting cases of hemorrhagic transformation not detected by CT. For the diagnosis of any hemorrhage, MRI was positive in 71 patients with CT positive in 29 (P<.001). For the diagnosis of acute hemorrhage, MRI and CT were equivalent (96 percent concordance). Acute hemorrhage was diagnosed in 25 patients on both MRI and CT. In four other patients, acute hemorrhage was present on MRI but not on the corresponding CT—each of these four cases was interpreted as hemorrhagic transformation of an ischemic infarct. They concluded that MRI may be as accurate as CT for the detection of acute hemorrhage in patients presenting with acute focal stroke symptoms and is more accurate than CT for the detection of chronic intracerebral hemorrhage.

    A recent publication of the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial reviewed the data to define the frequency of and risk factors for TE with rFVIIa.254 The analysis included 841 patients presenting <3 hours after spontaneous intracerebral hemorrhage who were randomized to 20 or 80 μg/kg of rFVIIa or placebo. Those with Glasgow Coma Scale score <5, planned early surgery, Coagulopathy, or recent TE were excluded. Myocardial, cerebral, or venous TEs were subject to detailed reporting and expedited local review. A blinded Data Monitoring Committee reviewed all electrocardiograms, centrally analyzed troponin I values, and CT scans.  The study found 178 arterial and 47 venous TEs had occurred. Venous events were similar across groups. There were 49 (27%) arterial events in the placebo group, 47 (26%) in the 20-μg/kg group, and 82 (46%) in the 80 μg/kg group (P=0.04). Of the myocardial events, 38 were investigator-reported and 103 identified by the Data Monitoring Committee. They occurred in 17 (6.3%) placebo and 57 (9.9%) rFVIIa patients (P=0.09). Arterial TEs were associated with: receiving 80 μg/kg rFVIIa (OR=2.14; P=0.031), signs of cardiac or cerebral ischemia at presentation (OR=4.19; P=0.010), age (OR=1.14/5 years; P=0.0123), and prior use of antiplatelet agents (OR=1.83; P=0.035). Ischemic strokes possibly related to study drug occurred in seven, five, and eight patients in the placebo, 20 μg/kg, and 80-μg/kg groups, respectively. The authors concluded that higher doses of rFVIIa in a high-risk population are associated with a small increased risk of what are usually minor cardiac events. Future consideration should be given to the effectiveness of rFVIIa in slowing bleeding balanced with  the risk of a small increase in arterial TEs.

    A Cochrane review (2008) assessed the effects of surgery plus routine medical management, compared with routine medical management alone, in patients with primary supratentorial intracerebral hematoma.263 Randomized and quasi-randomized trials of routine medical treatment plus intracranial

    surgery compared with routine medical treatment, in patients with presumed or confirmed primary supratentorial intracerebral hematoma. Intracranial surgery included craniotomy, stereotactic endoscopic evacuation, or stereotactic aspiration. Four trials were included (non-blinded). Craniotomy and endoscopic evacuation were analyzed separately. Craniotomy showed a non-significant trend towards increased odds of death and dependency among survivors (OR 1.99, 99% CI 0.92 to 4.31). The result was inconclusive in the two trials with patients confirmed as having primary supratentorial intracerebral hematoma by computed tomography. Endoscopic evacuation was not shown to significantly decrease the odds of death and dependency among survivors in one trial involving 100 patients (OR 0.45, 99% CI 0.15 to 1.33). The authors concluded current evidence could not evaluate the effect of craniotomy or stereotactic surgery, or endoscopic evacuation in patients with supratentorial intracerebral hematoma.

    Stroke Unit: In a prospective randomized study comparing mortality rates among intracranial hemorrhage patients managed on an acute stroke unit versus medical ward, Ronning et al. (2001) found that stroke unit care was associated with reduced mortality at 30 days (39% vs. 63%, p=0.007) and one year (52% vs. 69%, p=0.013).264 Diringer and Edwards (2001) prospectively followed and analyzed 1,038 ICH patients admitted to a neuro-ICU compared to a general ICU.265The thirteen ICUs that admitted >20 patients accounted for 83 percent of the admissions with a mortality rate that ranged from 25 percent to 64 percent. Multivariate analysis adjusted for patient demographics, severity of ICH, and ICU and institutional characteristics indicated that not being in a neuro ICU was associated with an increase in hospital mortality rate (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.65-7.6). Other factors associated with higher mortality rate were greater age (OR, 1.03/year; 95% CI, 1.01-1.04), lower Glasgow Coma Scale score (OR, 0.6/point; 95% CI, 0.58-0.65), fewer ICH patients (OR, 1.01/patient; 95% CI, 1.00-1.01), and smaller ICU (OR, 1.1/bed; 95% CI, 1.02-1.13). Having a full time intensivist was associated with lower mortality rate (OR, 0.388; 95% CI, 0.22-0.67).