Intracranial Hemorrhage: Management

00:01 Now, let’s talk about treatment of intracranial hemorrhages.

00:06 So, the first thing we think about in managing patients with intracranial hemorrhage is what is the cause of the intracranial hemorrhage, and knowing the cause can help us to guide the management of those patients. When we talked about causes, there were 5 major categories of causes of intracranial hemorrhage. We talked about hypertensive hemorrhage, hemorrhagic transformation of ischemic strokes, amyloid angiopathy, vascular lesions and tumors like metastases or primary brain tumors. And if we can determine the cause of the hemorrhage, that helps to guide us in how we will manage those patients. For patients presenting with hypertensive hemorrhage, the most important management is control of blood pressure. Early control of blood pressure prevents propagation or expansion of hemorrhage and is ultimately the best long-term therapy for those patients. We will consider MRIs of the brain to evaluate for other potential causes and confirm the most likely etiology of hypertensive hemorrhage. For patients presenting with a hemorrhagic transformation of ischemic stroke, this typically occurs within the 3 to 5 or 7 days following an initial ischemic infarct and that presentation should give us concern for a hemorrhagic transformation. We may consider MRI of the brain or additional ischemic stroke evaluation in those patients if not already performed.

01:21 In patients with amyloid angiopathy, MRI of the brain with susceptibility weighted image is important. Those patients present with lobar hemorrhages, often with small micro hemorrhages that are only evident on the susceptibility weighted image, and that imaging technique really helps to guide us in the diagnosis of those patients in long-term management. Vascular lesions need to be evaluated by vascular imaging and that may include CTA or catheter angiography to evaluate the cause location and best intervention for an underlying cerebrovascular lesion. And for tumors, MRI of the brain is the diagnostic modality of choice for evaluating the type of underlying lesion.

02:02 Unfortunately, often that hemorrhage initially obscures evaluation of the underlying lesion and we often need subsequent imaging at 4, 6 or sometimes 8 weeks after their initial presentation to establish an ultimate diagnosis. Our next question in managing these patients is, “Is surgery needed?” Oftentimes, these hemorrhages are emergencies initially, some can be managed conservatively. In fact, the vast majority of patients will be managed conservatively but surgery may be needed to manage the underlying lesion or evacuate the blood in patients who have declining clinical symptoms. Surgery is rare in patients with intracerebral hemorrhage. It is reserved for lesions that are suspicious for an underlying tumor or rapid and severe clinical deterioration. That's really important. We will hospitalize these patients and monitor them closely within those first 24 to 48 hours to evaluate those patients who may suffer clinical deterioration and require early intervention with neurosurgery. What are the conservative steps that we can do to help manage patients who do not require surgery for treatment of their intracranial hemorrhage. Well, I like to think of 3 categories of things that we can do. The first is to manage blood pressure. And that's important regardless of the cause and regardless of the underlying etiology. So, really important for patients with hypertensive hemorrhages but we want to manage blood pressure in any patient presenting with an intraparenchymal or intracranial hemorrhage. We typically consider a goal systolic blood pressure of less than 160 as our target. The second goal is to reduce re-bleeding risk. We hold antithrombotics, reverse anticoagulants, and avoid medications that could result in coagulopathy. We evaluate for coagulopathy and manage that risk in patients who may have an inherited or a newly acquired cause of increased hemorrhage risk or coagulopathy. And then the last is to manage secondary complications. Patients who are immobile may be at higher risk of DVT. We want to consider DVT prophylaxis initially with mechanical devices such as sequential compression devices and then ultimately as the hemorrhage has been determined to be stable we can consider chemical prophylaxis for DVT. We do need to consider the risk of seizures and patients with intracranial hemorrhage. That hemorrhage on the brain and particularly around the cortex of the brain can increase the likelihood of seizure.

04:26 We do not prophylax all patients with intracranial hemorrhages for seizures but in some patients particularly those with subdural hemorrhage or subarachnoid hemorrhage or lobar intraparenchymal hemorrhages we may consider seizure prophylaxis for a short period of time ranging from 1-4 weeks after the initial hemorrhage. Now let's talk about the second cause and major category of intraparenchymal hemorrhages and that's hemorrhagic transformation of an ischemic infarct. This is a patient that initially presented with acute onset of a left MCA syndrome, right hemibody weakness, and aphasia.

05:03 The patient underwent non-contrast head CT, CTA, and CT perfusion. CT perfusion looks at areas of low blood flow both infarcted territory that is lost and in penumbra territory that is at risk. Here we see CT perfusion showing a large area of ischemic penumbra in the left MCA territory and this is what's resulting in this patient's symptoms.

05:29 Here we're looking at the non-contrast head CT and the CTA that corresponds to that CT perfusion for this patient. On the non-contrast head CT to the left, we see early areas of ischemia in the subcortical regions and structures. We see blurring of the gray white junction in the insular cortex which is consistent with initial ischemic injury to that area and on the CTA we see a large proximal occlusion of the left MCA. If you look at the right MCA territory, there is good opacification and patency of the right MCA and a cutoff of the left MCA that's causing this perfusion change in the patient's symptoms and ultimately contributed to a large area of left MCA stroke. The MRI scan that corresponded to this for this patient didn't show a large area of diffusion restriction.

06:19 This was performed 24 hours into the hospitalization and we see this heterogenous signal. Around that same time, the patient had suffered a clinical decline and underwent non-contrast head CT which shows the reasons for this MRI imaging and the patient's clinical deterioration and that is an area of hemorrhage into this ischemic infarct.

06:38 We see an area of hyperdensity in that same subcortical region where we are seeing the early ischemic changes consistent with hemorrhagic transformation of this ischemic infarct. And this was confirmed on susceptibility weighted image on that same MRI scan.

06:53 On the far right, we see the susceptibility weighted image which shows us areas of hemorrhage and we see a large area of hemorrhage deep in this area of ischemic insult.

07:02 Hemorrhagic transformation after and ischemic infarct typically occurs in the first 3-5 days or sometimes out to 7 days. That's the period of time when the blood vessels are friable after an initial ischemic infarct. The risk of hemorrhagic transformation is greater in large strokes like we saw and are seeing for this patient and in patients who are already on pre-existing antiplatelet or anticoagulation therapy and these patients typically have a period of fixed deficit followed by clinical decline in the first 3-5 or up to 7 days. Now in contrast head CT should be performed and we'll demonstrate this area of hemorrhage which is often managed conservatively but may require surgical intervention.