Blood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies

Primary Thalamic Haemorrhage – Clinical Profile and Prognostic Predictors from a Series of 117 Cases

Background:

Studies on isolated primary thalamic hematomas are limited. This study analyses 117 patients with primary thalamic hematomas and attempts to identify the various prognostic factors influencing the outcome.

Materials and Methods:

A retrospective analysis of the case records was carried out to analyse the following prognostic parameters - GCS on admission, comorbidities like systemic hypertension and diabetes mellitus, side and site of hematoma, volume of the clot, presence of intraventricular haemorrhage (IVH), development of hydrocephalus, and the role of surgical intervention. A Chi-square test was used to compare categorical variables, and Student t-test and Mann Whitney test were applied to calculate the P-value for continuous variables for univariate statistics. Binary Logistic regression was used for multivariate analysis.

Results and Discussion:

This study group comprised 67 men and 50 women with a mean age of 62.05±11.71years. The mean GCS on admission in the study group was 11.56±3.28. The mean clot volume was 13±9.5ml and majority (89.74%) of the patients had clots with a volume of less than 20 ml. An intraventricular extension was noted in 98 patients. Craniotomy and surgical evacuation were performed in only two patients while external ventricular drainage with urokinase instillation was performed in 23 patients. Of the 117 patients, 3 had anterior thalamic clots, 19 had posterior thalamic clots, 13 had medial clots, 53 had lateral thalamic bleeds and 29 had global clots. The overall three-month mortality with thalamic bleeds was 28.2%. At the end of three months, 59 patients (50.42%) had a favourable outcome (mRS < 4). On univariate analysis, male sex, dominant side bleed, preoperative GCS of less than 8 (p < 0.001), presence of hydrocephalus (p< 0.004) and a need for EVD (p<0.012) were found to be significantly associated with mortality and poor outcome. Similarly, clot volume less than 20 ml, right-sided bleed and surgical evacuation were associated with a favourable outcome (p < 0.001). On multiple logistic regression, age, volume of hematoma and GCS on admission were predictors for mortality and volume of hematoma was a significant predictor of poor outcome.

Conclusion:

Thalamic hematomas include a spectrum of clots of varying dimensions at different locations and the outcomes need not be uniformly poor. Isolated thalamic hemorrhages are generally small in volume preferentially located in the lateral thalamus. Patients with right-sided bleeds and small clot volume perform well. Male sex, poor GCS on admission, clot volume above 20 ml, intraventricular extension and a need for external ventricular drainage adversely influence the outcome.

Bedside Intracranial Hematoma Evacuation and Intraparenchymal Drain Placement for Spontaneous Intracranial Hematoma Larger than 30cc in Volume: Institutional Experience and Patient Outcomes

Introduction:

Intracranial hemorrhage (ICH) accounts for significant morbidity and mortality in the United States. Many studies have looked at the benefits of surgical intervention for ICH. Recent results for Minimally Invasive Surgery Plus Recombinant Tissue-type Plasminogen Activator for Intracerebral Hemorrhage-II trials have shown promise for a minimally invasive clot evaluation on improving perihematomal edema. Often rural or busy county medical centers may not have the resources available for immediate operative procedures that are nonemergent. In addition, ICH disproportionally affects the elderly which may not be stable for general anesthetics. This study looks at a minimally invasive bedside approach under conscious sedation for evacuation of ICH.

Materials and Methods:

Placement of the intraparenchymal hemorrhage drain utilizes bony anatomical landmarks referenced from computed tomography (CT) head to localize the entry point for the trajectory of drain placement. Using the hand twist drill intracranial access is gained the clot accessed with a brain needle. A Frazier suction tip with stylet is inserted along the tract then the stylet is removed. The clot is then aspirated, and suction is then turned off, and Frazier sucker is removed. A trauma style ventricular catheter is then passed down the tract into the center of hematoma and if no active bleeding is noted on postplacement CT and catheter is in an acceptable position then 2 mg recombinant tissue plasminogen activator are administered through the catheter and remaining clot is allowed to drain over days.

Results:

A total of 12 patients were treated from October 2014 to December 2017. The average treatment was 6.4 days. The glascow coma scale score improved on an average from 8 to 11 posttreatment with a value of P is 0.094. The average clot size was reduced by 77% with a value of P = 0.0000035. All patients experienced an improvement in expected mortality when compared to the predicted ICH score.

Discussion:

The results for our series of 12 patients show a trend toward improvement in Glasgow Coma Scale after treatment with minimally invasive intraparenchymal clot evacuation and drain placement at the bedside; although, it did not reach statistical significance. There was a reduction in clot size after treatment, which was statistically significant. In addition, the 30-day mortality actually observed in our patients was lower than that estimated using ICH score. Based on our experience, this procedure can be safely performed at the bedside and has resulted in better outcomes for these patients.

Blood pressure control for acute severe ischemic and hemorrhagic stroke

PURPOSE OF REVIEW

Severe ischemic or hemorrhagic stroke is a devastating cerebrovascular disease often demanding critical care. Optimal management of blood pressure (BP) in the acute phase is controversial. The purpose of this review is to display insights from recent studies on BP control in both conditions.

RECENT FINDINGS

BP control in acute ischemic stroke has recently been investigated with regard to endovascular recanalizing therapies. Decreases from baseline BP and hypotension during the intervention have been found detrimental. Overall, a periinterventional SBP between 140 and 160 mmHg appeared favorable in several studies. In acute hemorrhagic stroke, the recently completed Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial confirmed feasibility of early aggressive BP reduction but failed to demonstrate a reduction in hematoma growth or a clinical benefit.

SUMMARY

Recent findings do not support benefits of intensive BP lowering in both acute hemorrhagic and ischemic stroke, with the possible exception of the postinterventional phase after successful endovascular recanalization of large-vessel occlusions. Although optimal ranges of BP values remain to be defined, high BP should still be treated according to guidelines. As stroke patients requiring critical care are underrepresented in most studies on BP, caution in transferring these findings is warranted and prospective research in that patient population needed.

[Critical care management of intracerebral hemorrhage]

BACKGROUND

Intracerebral hemorrhage accounts for up to 20 % percent of all ischemic strokes. In addition to a higher mortality, they are often associated with severe neurological impairment for those affected.

OBJECTIVES

Review of the current literature and guidelines addressing the critical care management of spontaneous intracerebral hemorrhage, including treatments to reduce primary and secondary neurological damage.

RESULTS

Acute blood pressure lowering to less than 140 mmHg should be aspired immediately after intensive care admission. During the following days blood pressure variability should be minimized. Preexisting oral anticoagulation should be immediately reversed, while hemostatic therapy not associated with reversal of antithrombotic therapy should not be applied. Surgery for patients with impaired consciousness should be discussed. Use of pneumatic compression in immobile patients is recommended. Developing intracranial hypertension should be treated with combined physical and pharmacological measures in a stepwise approach. Administration of glucocorticoids is currently not recommended.

CONCLUSIONS

Critical care management of spontaneous hemorrhage demands a multimodal, graded approach for reduction of both primary and secondary neurological damage.

Prognostic Factors of Clinical Outcomes in Patients with Spontaneous Thalamic Hemorrhage

Background

Intracerebral hemorrhage (ICH) is a well-known condition, but ICH restricted to the thalamus is less widely studied. We investigated the prognostic factors of thalamic ICHs.

Material/Methods

Seventy patients from January 2009 to November 2014 were retrospectively reviewed. Patients who demonstrated spontaneous ICH primarily affecting the thalamus on initial brain computed tomography (CT) were enrolled. Patients were categorized into 2 groups based on their Glasgow Outcome Scale (GOS) scores. Various presumptive prognostic factors were analyzed to investigate relationships between various clinical characteristics and outcomes.

Results

Of the enrolled patients, 39 showed a GOS of 4–5, and were categorized as the good outcome group, while another 31 patients showed a GOS of 1–3 and were categorized as the poor outcome group. Initial GCS score, calculated volume of hematoma, presence of intraventricular hemorrhage (IVH), coexisting complications, hydrocephalus, performance of external ventricular drainage, and modified Graeb’s scores of patients with IVH were significantly different between the 2 groups. In multivariate analysis, among the factors above, initial GCS score (P=0.002, Odds ratio [OR]=1.761, Confidence interval [CI]=1.223–2.536) and the existence of systemic complications (P=0.015, OR=0.059, CI=0.006–0.573) were independently associated with clinical outcomes. Calculated hematoma volume showed a borderline relationship with outcomes (P=0.079, OR=0.920, CI=0.839–1.010).

Conclusions

Initial GCS score and the existence of systemic complications were strong predictive factors for prognosis of thalamic ICH. Calculated hematoma volume also had predictive value for clinical outcomes.