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Research Horizons in the Acute Management of ICH

Research Horizons in the Acute Management of ICH. Edward C. Jauch, MD MS FACEP Assistant Professor Associate Director of Research Department of Emergency Medicine University of Cincinnati College of Medicine Faculty, Greater Cincinnati / Northern Kentucky Stroke Team.

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Research Horizons in the Acute Management of ICH

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  1. Research Horizons in the Acute Management of ICH

  2. Edward C. Jauch, MD MS FACEPAssistant ProfessorAssociate Director of ResearchDepartment of Emergency MedicineUniversity of Cincinnati College of MedicineFaculty, Greater Cincinnati / Northern Kentucky Stroke Team

  3. Current Recommendations for Management of Intracerebral Hemorrhage • Emergency Medicine representation • New guidelines due 2005 Edward C. Jauch, MD MS FACEP (Broderick, Stroke 1999)

  4. Medical Management • ABC’s • Blood pressure control • ICP management • Hyperventilation • Osmotherapy • No role for glycerol, corticosteroids, hemodilution • Other • Prevention of hyperthermia • Fluid management (CVP at 5-12 mm Hg) • Modifications for age, comorbidities, size, severity, location • Seizure control • Find somebody to take the patient

  5. The Future of ICH Treatment Edward C. Jauch, MD MS FACEP

  6. Time Will Always Mean Brain! (Lancet 2004; 363: 768–74)

  7. Priorities and Potential for ICH Treatment • Prevention of primary and secondary injury: • Goal directed physiologic management • Systemic • Local • Minimize edema/hematoma growth and injury • Anticoagulation reversal • Maximize hemostasis • Penumbral protection • Early hematoma evacuation / decompression

  8. Blood Pressure Management Edward C. Jauch, MD MS FACEP (Broderick, Stroke 1999)

  9. Blood Pressure Management • No definitive data (yet) • Hypertension very common • MAP > 140 in 34%, > 120 in 78% • Many return to baseline over first 24 hours (Dr. Aninda Acharya, St.Louis University, Internet Stroke Center)

  10. Blood Pressure Management • Balancing act to minimize hematoma expansion while maximizing perihematomal ischemia • Antihypertensive Treatment in Acute ICH • Stepwise intervention with nicardipine to lower SBP (R01NS044976) • Safety trial and secondary efficacy outcome

  11. Penumbral Protection • Neurotoxicity and the ischemic cascade occur very early • Trials to blunt this response: • FAST-Mag (Phase III) • Trial of magnesium in AIS and ICH • CHANT (NXY-059) (Phase II) • Localized hypothermia (animal studies)

  12. Hematoma and Edema Management • Treatment within four hours from onset • 399 patients in 4 arms (40, 80, 160 μg/kg) • Outcomes • Primary: 24 hour hematoma growth • Secondary: 90 day outcomes (Mayer, NEJM 2005;352:777-785)

  13. Factor rVIIa Treatment P=0.07 P=0.05 P=0.02

  14. Factor rVIIa Treatment • rFVIIa limits ICH growth, reduces mortality, and improves functional outcomes • A small increase in the frequency of thromboembolic adverse events occurs with treatment (2% vs 7%, p=0.12) (Mayer, NEJM 2005;352:777-785)

  15. Surgical Approaches • Decompressive surgery • Hematoma removal / aspiration • Intraventricular drainage and hematoma removal

  16. Surgical Recommendations Edward C. Jauch, MD MS FACEP (Broderick, Stroke 1999)

  17. Surgical Evacuation • Largest surgical trial (1033 patients, 27 countries, 8 years) • Surgery within 96 hours from onset vs medical management • Outcome • Primary Favorable outcome at 6 months • Secondary Mortality (Mendelow, Lancet 2005;365:387-397)

  18. Surgical Evacuation • No difference in: • Favorable outcome (26% vs. 24%, OR 2.3) • Mortality (36% vs 37%, OR 1.2) • Mean total 6 month cost (£18452 vs £20513) Mortality curves (Mendelow, Lancet 2005;365:387-397)

  19. MISTIE Trial • Stereotactic ICH evacuation with tPA • Multicenter phase II NIH study • Surgery in 24 hrs from onset • Stable clot for 6 hrs on serial CT • Similar dose-escalation tPA evacuation trials of IVH alone and IVH associated with ICH (DITCH Trial phase II)

  20. Conclusions • All forms of brain injury, from trauma to vascular events, will require rapid interventions • Immediate global and local treatments will be the purview of the Emergency physician • Time will always be brain

  21. Questions??www.ferne.orgferne@ferne.orgEdward Jauch, MD, MSjauchec@ucmail.uc.edu(513) 558-0474 Edward C. Jauch, MD, MS FACEP ferne_acep_2005_jauch_ich_reshorizon_cd 3/2/2005 4:21 PM

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