New ED treatments for intracerebral hemorrhage

Don't assume nothing can be done

A new medication holds promise for slowing bleeding from intracerebral hemorrhage (ICH), according to updated guidelines from the American Heart Association and the American Stroke Association. Recombinant activated factor VII (rFVIIa) is a drug that slows down bleeding and is approved to treat patients with hemophilia, says Joseph Broderick, MD, chair of the guideline writing committee and professor and chairman in the Neurology Department of the University of Cincinnati Medical Center.1

Recent presentation of the FAST Trial results confirmed that rFVIIa slows bleeding when given within the first three to four hours after onset, he notes. "RFVIIa is mentioned as a potential new treatment that needs further study," Broderick says. "However, the efficacy and safety of this treatment must be established in a Phase III trial before its use in patients with ICH can be recommended outside of a clinical trial."

With ICH, there is a misconception that nothing can be done, says Gena Kreiner, CCRN, stroke coordinator at St. Joseph Medical Center in Tacoma, WA. "The belief is that the damage is done," she says. "Because the new guidelines suggest that ffactor VII may be used to slow the bleeding, the window of time that this can be done will affect the urgency in getting these patients to CT scan and receiving treatment. It would be what tPA is to an ischemic."

Preventing secondary brain injury in a hemorrhagic stroke patient is just as important as preventing secondary injury in head trauma, says Kreiner. "This would include avoiding hypotension as well as hypertension," she says. "Cerebral perfusion is important in the prevention of secondary injury."

Also, ICH is "still a stroke," and the National Institutes of Health Stroke Scale should be performed on these patients just as with ischemic stroke, says Kreiner.

ICH accounts for less than 10% of first-ever strokes, with 35%-52% of patients dying within a month. Of the estimated more than 60,000 patients who have an ICH in a year, only 20% are expected to be functionally independent six months afterward.2

Reducing high blood pressure still is the best way to avoid ICH, says Broderick. "ICH is the second most common type of stroke, and its incidence is staying the same or slightly increasing," he says. "The time is right for updating the guidelines because there have been a number of published studies that may affect how we manage these very sick patients."

Here are other key changes that will affect ED nurses:

• Feasibility and timing of surgical options.

"We don't recommend routine surgical treatment of ICH, but people who have larger blood clots close to the surface of the brain or with larger hemorrhages in the cerebellum may be candidates," says Broderick. "Research is ongoing to explore less invasive and more precise surgical methods to remove blood."

• New prevention strategies.

"Treating high blood pressure remains the most important target for preventing ICH," stresses Broderick. Smoking cigarettes, heavy alcohol use and cocaine, all risk factors for ICH, should be discontinued to prevent recurrent ICH, say the guidelines.

• New warning signs for recognizing ICH.

Headache and vomiting are more common with ICH than with other types of stroke, according to the guidelines.

• Different ways to take pictures of the brain to diagnose a hemorrhagic stroke.

CT and magnetic resonance imaging (MRI) scans appear equal in the ability to identify the ICH, its size and location and ongoing bleeding, according to the updated guidelines.

"Before, a CT scan was the primary option for evaluating stroke patients in an emergency. Data now show that MRI scans also do the job and both are first-choice options," Broderick says. In patients with contraindications to MRI, such as those with pacemakers, CT should be obtained, he notes.

Each type of imaging has benefits: CT is better at showing associated ventricular extension, while MR is better at detecting underlying structural lesions in the brain, says Broderick. "MR is also better than CT at showing tiny old hemorrhages in the brain. However, MR is not always as practical as the faster CT scan for patients who are unconsciousness, vomiting, or on a ventilator," he says.

Blood pressure is "very much the topic" when a patient has ICH, says Kathleen Kearns, RN, nurse coordinator for the stroke center at Providence St. Vincent Medical Center in Portland, OR.

"The ED nurse needs to be aware that the 'permissive hypertension' for these types of stroke patients is not as high as those patients with ischemic strokes," says Kearns. "So the ED nurse needs to be monitoring carefully." Systolic blood pressure over 180 without suspicion of elevated intracranial pressure can be reduced to a target of 160, she says.

Monitor blood pressure every 15 minutes unless you are aggressively treating the pressure and working to get it down, in which case reassessment should be done every five minutes, says Kearns.

No antithrombotics, anticoagulants, or thrombolytics should be given before the CT results are known, stresses Kearns. "Knowing the PT/PTT/INR is important, so you can be thinking ahead of possible reversal of anticoagulant therapy if patient has had a bleed and has been on anticoagulant therapy," says Kearns.

References

  1. Broderick J, Connolly S, Feldman E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults. Stroke 2007; 38:2,001-2,023.
  2. Counsell C, Boonyakarnkul S, Dennis M, et al. Primary intracerebral haemorrhage in the Oxfordshire Community Stroke Project, 2: prognosis. Cerebrovasc Dis 1995; 5:26-34.

Sources/Resource

For more information on caring for intracerebral hemorrhage patients in the ED, contact:

  • Joseph Broderick, MD, Professor and Chairman, Neurology Department, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0525. Phone: (513) 558-5429. E-mail: joseph.broderick@uc.edu.
  • Kathleen Kearns, RN, Nurse Coordinator, Providence Stroke Center, Providence St. Vincent Medical Center, 9205 S.W. Barnes Road, Portland, OR 97225. Phone: (503) 216-4247. E-mail: kathleen.kearns@providence.org.
  • Gena Kreiner, CCRN, Stroke Coordinator, St. Joseph Medical Center, 1717 S. J St., Tacoma, WA 98405. E-mail: GenaKreiner@fhshealth.org.

The Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults can be downloaded at no charge at http://stroke.aha journals.org. Or a single reprint is available at no charge. Contact the American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Phone: (800) 242-8721. Ask for reprint number 71-0411.