Intracerebral Hemorrhage (ICH):
Update on Medical and Surgical
Treatments
Paul M. Vespa, MD, FCCM, FANA, FAAN, FNCSAssistant Dean of Research in Critical Care
Gary L. Brinderson Chair of Neurocritical Care
Professor of Neurosurgery and Neurology
Director of Neurocritical Care
David Geffen School of Medicine at UCLA
Conflicts of Interest
• Portola, UCB, Ceribell – consultant
• NIH Funding for MISTIE, ICES, CLEAR
Overview
• Updates on treatment considerations for
ICH
• Topics
– Hemorrhagic expansion
– Blood pressure management
– Minimally invasive surgical options
Hemorrhagic Expansion of ICH30-40% will have expansion
Occurs in first few hours
Bornes, Butcher
Coagulation System and Reversal Agents
Jin et al plasminogen
Plasmin
Fibrin split products
TXA
PCC or Andexanet alfa
PCC or Idarucizumab
(dabigatran)
PCC
PCC off label alert
PCC off label alert
PCC off label alert
• ICH patients
• RCT
– Platelet transfusion
– Control – no transfusion
• Transfusion - control
• ICH vol 13.1 - 8 cc
• GCS 14 - 15
• ICH> 30 cc 34% - 21%
No difference in functional outcome at 90 days, p = 0.11
PCC off label alert
Controlling Blood Pressure
• Hypertension is common after ICH
• Quite high BP occur
• The BP is often resistant to treatment
• With elevated ICP one needs an adequate
cerebral perfusion pressure (MAP- ICP =
CPP)
• But too high BP may result in hemorrhagic
expansion
AHA guidelines 2015
Slides are courtesy of Craig Anderson
INTERACT 2 Study
Protocol schemafrom INTERACT1 (Lancet Neurol 2008) and INTERACT 2 (Int J Stroke 2010)
Acute spontaneous ICH confirmed by CT/MRI
Definite time of onset within 6 hours
Systolic BP 150 to 220 mmHg
No indication/contraindication to treatment
In-hospital vital signs, NIHSS, GCS and BP over 7 days
Intensive BP lowering
SBP <140 mmHg
Standard BP management
Guidelines SBP <180 mmHg)
R
16
Independent 90 day outcome with modified Rankin scale (mRS)
POWER CALCULATION FOR INTERACT 2
N=2800 gives 90% power for 7% absolute (14% relative) decrease (50% standard vs 43% intensive) in outcome Slides are courtesy of Craig Anderson
Systolic BP time trends1 hour - Δ14 mmHg (P<0.0001)6 hour - Δ14 mmHg (P<0.0001)
Systolic BP controlMedian (iqr) time to treatment, hr - intensive 4 (3-5), standard 5 (3-7)
Intensive group to target (<140mmHg)462 (33%) at 1 hour731 (53%) at 6 hours
Me
an
Systo
lic B
loo
d P
ressu
re (
mm
H
g)
0
110
120
130
140
150
160
170
180
190
200
R 15 30 45 60 6 12 18 24 2 3 4 5 6 7
StandardIntensive
////
Minutes Hours Days / Time
164
153
150
139
am pm am pm am pm am pm am pm am pm
P<0.0001
beyond 15mins
Target level
17Slides are courtesy of Craig Anderson
Primary clinical outcomeDeath or major disability (mRS 3-6) at 90 days
%
(N=1399) (N=1430)
52.0%55.6%
Odds ratio 0.87 (95%CI 0.75 to 1.01) P=0.06
18Slides are courtesy of Craig Anderson
Key secondary outcomeOrdinal shift in mRS scores (0-6)
Odds ratio 0.87 (95%CI 0.77 to 1.00); P=0.04
19
18.0% 18.8% 16.6% 19.0%
\
12.0%8.0%
0 1 2 3 4 5 6
Intensive
Standard
Major disability DeathDisability but independent
18.7% 15.9% 18.1% 6.0%21.1%8.1% 12.0%
7.6%
Slides are courtesy of Craig Anderson
June 8, 2016
ATACH 2
ATACH 2 – Qureshi et al 2016
ATACH 2
More Adverse events in the SBP 110-139 group (25.6% vs 20%, p < 0.05
The Rate of AKI was double in the SBP 110-139 group (9% vs 4%) p < 0.002
Seizures in the ICU after ICH
• cEEG monitoring in coma patients with ICH
• 20-35% incidence of seizures
• Most are nonconvulsive
• Seizures associated with worsening brain edema,
ICP, midline shift
• Seizures may worsen outcome
• Treat seizures if they occur
Surgical Considerations
• Ventriculostomy and intrathecal tpa for
IVH
• Open Surgery for mass lesions with signs
of herniation
• Minimally invasive surgery for ICH
Dosing
CT scans
EVD
Day 1 2 3 4 5 6 7 30
= Diagnostic = Stability = Daily
365
Minimally Invasive Surgery
• Endoscopic evacuation of the hematoma
via stereotactic guidance
– ICES, SCUBA, ADAPT, etc.
• Thrombolytic administration and
hematoma dissolution slowly
– MISTIE
Rothrock et al 2020Awad, Hanley et al 2019
MISTIE III
MISTIE III
MISTIE III
MISTIE III
Overall less mortality in the MISTIE arm vs medical arm
If the ICH volume is reduced to < 15 ml, then the probability of a
good outcome, as indicated by modified Rankin 0-3 is high
Summary
• ICH is a treatable disease, but requires
intensive care
• Stop the bleeding early after ICH
• Blood pressure control
• Emerging information about surgery
