haemorrhagic stroke - ACEM Fellowship Notes

see also: [[Stroke|ischaemic stroke]], [[Warfarin, DOAC, heparin reversal|Reverse anticoagulation]] - [Evacuate ICH trial (cubox)](cubox://card?id=7144320348064842281) - [ICH Rosen](x-devonthink-item://34BCE5FA-5D8A-4BBE-9655-35F24866FDB1?page=16&start=1429&length=57&search=Spontaneous%20Intracerebral%20Hemorrhage%0A(Hemorrhagic%20Stroke)) - [Spont intracerebral Haemorrhage Dunn](x-devonthink-item://E6E88D61-CB07-49D8-B7B5-58D586132BC1) - [current management of spontaneous ICH bookends 2017](bookends://sonnysoftware.com/ref/DL/299170) - [2022 AHA guideline](https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000407) - [RMH Hyper-acute Stroke Management by the Stroke Team Protocol](x-devonthink-item://9FF55E37-4E4C-4CE2-9B00-F7353E58E17D) Relevant trials: - [[ATACH-2 Trial]] - [[INTERACT-2]] > [!key points] overview > - make up a majority of deaths even though only ~20% of all strokes > - TXA does not help > - consider EVD if raised ICP > - pontine bleed - pinpoint pupils ![[Pasted image 20240219135025.png]] # investigations **Spot sign** - spot-like, serpiginous, and/or linear shaped contrast extravasation around haemorrhage located within margin of parenchymal hematoma - density greater than background haematoma - no connection to a vessel outside haematoma margin - present in approximately 20% of cases - 50% sensitive, 90% specific for *haematoma expansion* # prognosis # Causes ![[Pasted image 20241023143713.png]] # management ## blood pressure > [!tldr] > - if SBP btwn 150-220, acute lowering of SBP to 140 safe and effective > - if SBP >220, target BP less clear > - [[Nicardipine]] and [[labetalol]] are drugs of choice (short t1/2, easy titration) > - **Avoid GTN** to avoid ↑ ICP - Two large phase III, multicenter, prospective randomized controlled trials (RCTs) have shown that **early lowering of SBP to less than 140 mm Hg** is safe without significant adversary effects. - [[INTERACT-2|INTERACT2]] and [[ATACH-2 Trial]] trials - However, ==a rapid and large reduction== (60 mm Hg) within 1 hour of the initiation of treatment was ==associated with some harm== - Therefore, for ICH patients presenting with *SBP between 150 and 220* mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe and can be effective for improving functional outcome. - For ICH patients presenting with *SBP greater than 220 mm Hg*, it may be reasonable to consider aggressive reduction of BP with a continuous IV infusion and frequent BP monitoring, but the target BP is less clear - use [[Nicardipine]] 5mg/H up to 16mg/hour by 2.5mg/h - **avoid GTN** to avoid cerebral vasodilation and elevated ICP | Drug | Mechanism | Dose | Cautions | | ------------- | ------------------------------------------------ | ------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------- | | Labetalol | Alpha-1, beta-1, beta-2 receptor antagonist | 10-80 mg bolus q10min, up to 300 mg; 0.5-2 mg/min infusion | Bradycardia, congestive heart failure, bronchospasm | | Esmolol | Beta-1 receptor antagonist | 0.5 mg/kg bolus; 50-300 μg/kg/min infusion | Bradycardia, congestive heart failure, bronchospasm | | Nicardipine | L-type calcium channel blocker (dihydropyridine) | 5-15 mg/h infusion | Severe aortic stenosis, myocardial ischaemia | | Enalaprilat | ACE inhibitor | 0.625 mg bolus; 1.25-5mg q6h | Variable response, precipitous fall in BP with high renin states | | Nitroprusside | Nitrovasodilator (arterial and venous) | 0.25-10 μg/kg/min | generally not reccomended in ICH because tendency to increased ICP. variable response, myocardial ischaemia, cyanide toxicity | ## seizures - treat with **levetiracetam** 1g to 1.5g IV ## elevated ICP See [[traumatic brain injury#Reducing ICP]] - in pts with radiographic hydrocephalus and/or decreased LOC, **external ventricular drain** may be advised - a CPP of 50-70 mmHg recommended - **mannitol** and **hypertonic saline** first line tx for patients with symptomatic cerebral oedema and elevated ICP - in INTERACT2, no difference in outcome in mannitol and non-mannitol treated patients - hypertonic saline may be slightly more effective than mannitol for tx of elevated ICP - if using hypertonic saline, target sodium 145 to 155 mmol/L - Mannitol 0.5-1 g/kg - HTS 3% 300mL over 30 min ## reverse anticoagulation see [[Warfarin, DOAC, heparin reversal]] ![[Pasted image 20240219135421.png]] | Scenario | Agent | Dose | Comments | | Level of Evidence | | ------------------------------------------- | -------------------------------- | -------------------------------------- | -------------------------------------------------- | --- | ----------------- | | Warfarin | FFP *or* | 15 mL/kg | Usually 4-6 U (200 mL) each are given | | B | | | PCC (prothrombinex) *and* | 15-30 U/kg | Works faster than FFP but carries risk of DIC | | B | | | IV Vitamin K | 10 mg | Can take up to 24 h to normalize INR | | B | | Warfarin and emergency NSx intervention | Above plus rFVIIa | 20-80 μg/kg | Contraindicated in acute thromboembolic disease | | C | | Unfractionated or LMWH | Protamine sulfate | 1 mg per 100 U heparin or 1mg LMWH | Can cause flushing, bradycardia, or hypotension | | C | | Platelet dysfunction or thrombocytopaenia | Platelet transfusion *and/or* | 6U | Range, 4-8 U based on size; transfuse to > 100,000 | | C | | | desmopressin (DDAVP) | 0.3 μg/kg | single dose required | | C | | Thrombin inhibitors (Dabigatran) | Oral charcoal *plus* | 15-30 U/kg 20-80 μg/kg | If ingestion < 2 h Risk of DIC | | C | | | PCC *plus* | | | | | | | rFVIIa plus | | | | | | | haemodialysis | | | | | | Factor Xa inhibitors (apixaban, xarelto) | rFVIIa | 20-80 μg/kg | | | C | # Related Questions ## haemorrhage - [ ] 17Q: [Haemorrhagic Stroke](x-devonthink-item://B74AA648-7583-42CC-9AC9-1FDBD09A2750?page=2) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=2) -- [prop](x-devonthink-item://5F365535-E019-4C8D-8402-2E764B328988?page=1)