Early hemorrhage growth in patients with intracerebral hemorrhage

Recommendations for the Management of Intracranial Haemorrhage – Part I: Spontaneous Intracerebral Haemorrhage

This article represents the recommendations for the management of spontaneous intracerebral haemorrhage of the European Stroke Initiative (EUSI). These recommendations are endorsed by the 3 European societies which are represented in the EUSI: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Accident vasculaire cérébral hémorragique : nouveautés sur la prise en charge

Haemorrhagic stroke is frequent and associated with a high mortality and morbidity. Less than 30% of patients are still alive five years after onset and few patients regain functional independence. The worsening effect of anticoagulation has been demonstrated and the failure to rapidly normalize coagulation further increases haematoma expansion. In a recent phase II trial, recombinant activated factor VII given within 4 hours of stroke onset, reduced haematoma growth, mortality and disability. An aggressive blood pressure and intracranial pressure control early after the haemorrhage seems beneficial. A large prospective randomized study (the STICH trial) did not demonstrate any beneficial effect of surgery.

Haemostatic drug therapies for acute primary intracerebral haemorrhage

BACKGROUND

Because primary intracerebral haemorrhage (PICH) volume influences its outcome and a third of PICHs enlarge by a third within 24 hours of onset, early haemostatic drug therapy might improve outcome.

OBJECTIVES

To examine the clinical effectiveness and safety of haemostatic drug therapies for acute PICH in a randomised controlled trial (RCT) design.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched May 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to August 2005) and EMBASE (1980 to August 2005). In an effort to identify further published, ongoing and unpublished studies we scanned bibliographies of relevant articles, searched international registers of clinical trials and research, and contacted authors and pharmaceutical companies.

SELECTION CRITERIA

We sought RCTs of any haemostatic drug therapy for acute PICH, compared against placebo or open control, with relevant clinical outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, reviewed the relevant studies, and extracted data from them.

MAIN RESULTS

We found four phase II RCTs, involving adults aged 18 years or over, within four hours of PICH: 116 received placebo and 373 participants received haemostatic drugs (two received epsilon-aminocaproic acid (EACA) and 371 received recombinant activated factor VII (rFVIIa)). Haemostatic drugs appeared to reduce the risk of death or dependence on the modified Rankin Scale (grades 4 to 6) within 90 days of PICH (risk reduction 0.79 (95% confidence intervals (CI) 0.67 to 0.93)), but not when assessed by the extended Glasgow Outcome Scale (risk reduction 0.90 (95%CI 0.81 to 1.01)). There was a statistically significant excess of arterial thromboembolism at 160 mcg/kg rFVIIa.

AUTHORS' CONCLUSIONS

Current evidence for the use of haemostatic drugs in the treatment of acute PICH cannot provide clear guidelines for clinical practice. Adults with acute PICH may benefit from haemostatic therapy with rFVIIa, but the evidence on major clinical outcomes is neither robust nor precise. Large phase III RCTs of rFVIIa - and other less costly drugs - are necessary.

Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines

OBJECTIVE

To determine the feasibility and safety of treatment of acute hypertension in patients with intracerebral hemorrhage within 24 hrs of symptom onset. Elevated blood pressure, observed in up to 56% of patients with intracerebral hemorrhage, may predispose to hematoma expansion; on the other hand, reduction of blood pressure may reduce hematoma expansion and subsequent death and disability.

DESIGN

Single-center prospective registry supplemented by retrospective chart review.

SETTINGS

University-affiliated medical center with dedicated stroke service.

PATIENTS

All patients admitted to the stroke service with spontaneous intracerebral hemorrhage and acute hypertension within 24 hrs of symptom onset.

INTERVENTION

Patients were treated with intravenous nicardipine within 24 hrs of symptom onset to reduce and maintain mean arterial pressure of <130 mm Hg. The mean arterial pressure goal was consistent with the American Heart Association guidelines.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the tolerability of the treatment as assessed by achieving and maintaining the mean arterial pressure goals for 24 hrs after initiation of intravenous nicardipine infusion. Other end points ascertained were: neurologic deterioration defined by a decline in Glasgow Coma Scale from pretreatment assessment by >or=2 points or increase in National Institutes of Health Stroke Scale score by >or=2 points and hemorrhage growth defined as an increase in the volume of intraparenchymal hemorrhage of >33% as measured by image analysis on the 24-hr computed tomographic scan compared with the baseline computed tomographic scan. Rates of favorable outcome and death were ascertained at 1 month. Of the total 46 patients admitted with intracerebral hemorrhage in our service, 29 patients were treated. Mean age of the treated patients was 58 +/- 13 yrs; ten were women. Initial National Institutes of Health Stroke Scale ranged from 1 to 38. The primary outcome of tolerability was achieved in 25 of the 29 patients (86%). Neurologic deterioration was observed in 4 of 29 patients. Hematoma enlargement was observed in five patients. Favorable outcome (defined as modified Rankin scale of <or=2) and death at 1-month was observed in 11 (38%) and 9 (31%) of the 29 patients, respectively.

CONCLUSIONS

We observed a high rate of tolerability among patients with intracerebral hemorrhage who were treated with intravenous nicardipine using mean arterial pressure goals defined by American Heart Association guidelines within 24 hrs of symptom onset.

Hemostatic therapy for intracerebral hemorrhage

Despite the highest mortality and morbidity of all forms of stroke, few advances have been made in the management of intracerebral hemorrhage (ICH). Besides specialized care in the stroke or neurologic intensive care unit, until very recently no specific therapies have been shown to improve outcome after ICH. Ventilatory support, blood pressure reduction, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Recently, a phase II trial of recombinant activated factor VII (NovoSeven; Novo Nordisk, Bagsvaerd, Denmark) reduced hematoma expansion, mortality, and disability when given within 3 hours of ICH onset. A phase III trial to confirm these results is now in progress.

[Intracerebral hemorrhage related to anticoagulant therapy]

Intracerebral hemorrhage (ICH) is the most serious complication of oral anticoagulant therapy (OAT). The growing use of OAT has resulted in an increase of fatal ICH. The mortality rate is about 65%, and most of the surviving patients remain disabled. While improvements in the treatment of spontaneous ICH have recently been described, there are no internationally accepted guidelines for managing patients with OAT-ICH. Therefore, identifying effective treatments is essential for improving clinical outcome. This article reviews the epidemiology of OAT-ICH, its pathophysiology, and current treatment options and discusses open questions with particular respect to more recent pharmacological therapies.

Geriatric neurologic emergencies

Geriatrics is an important subspecialty within the field of emergency medicine and represents a burgeoning area of practice. The special vulnerability of elderly patients to neurologic disease and injury and the comparative subtlety of clinical presentation mean that physicians should have a lower threshold for laboratory studies, radiologic imaging, consultation, and admission. Transferring appropriate patients to tertiary centers that offer specialized trauma and neurologic and neurosurgical care greatly enhances survival and functional outcomes.

Rapid administration of antifibrinolytics and strict blood pressure control for intracerebral hemorrhage

OBJECTIVE

Hematoma growth is a major cause of poor outcome in patients with intracerebral hemorrhage. We evaluated the efficacy of a combination of rapid antifibrinolytic therapy and strict blood pressure control for prevention of hematoma growth in this retrospective study.

METHODS

Systolic blood pressure was strictly controlled below 150 mm Hg by use of intravenously administered nicardipine (BPC). Prolonged infusion of antifibrinolytic therapy was given by intravenous administration of 1 g tranexamic acid over a period of 6 hours (PAF). Rapid administration of antifibrinolytic therapy was given by intravenous administration of 2 g tranexamic acid over a period of 10 minutes (RAF). Immediately after diagnosis of intracerebral hemorrhage on computed tomographic scan, 156 patients who were admitted within 24 hours of onset were treated with either a combination of PAF and BPC (PAF group) or a combination of RAF and BPC (RAF group). The incidence of hematoma growth determined by a second computed tomographic scan the day after admission was compared between the PAF and the RAF groups.

RESULTS

Hematoma growth was observed in 11 (17.5%) of 63 patients in the PAF group and 4 (4.3%) of 93 patients in the RAF group using a 20% cutoff value for hematoma enlargement. The RAF group showed a significantly low incidence of hematoma growth compared with the PAF group (P < 0.05). Between the two groups, there was no significant difference in any of the other factors reported to affect hematoma growth.

CONCLUSION

The combination of rapid administration of antifibrinolytics and strict blood pressure control may prevent hematoma growth in patients with intracerebral hemorrhage.

Treating the acute stroke patient as an emergency: current practices and future opportunities

Developments in acute stroke therapy have followed advances in the understanding of the evolving pathophysiology in both ischaemic stroke and intracerebral haemorrhage (ICH). In ischaemic stroke, rapid reperfusion of the ischaemic penumbra with thrombolysis within 3 h of symptom onset is of proven benefit, but few patients currently receive therapy, mainly due to the short-time window and lack of stroke expertise. In ICH, a recent study indicated that a haemostatic agent can limit ongoing bleeding and improve outcomes when administered within 4 h of stroke onset. These advances in acute stroke therapy underlie the concept that 'time is brain' and that urgent intervention can limit cerebral damage. Neuroprotective therapy could offer the prospect of a greater proportion of stroke patients receiving treatment, potentially before imaging and even in the ambulance setting. Virtually all stroke patients would benefit from receiving multidisciplinary care in acute stroke units.

Memantine reduces hematoma expansion in experimental intracerebral hemorrhage, resulting in functional improvement

Glutamate is accumulated in abundance during the early period of experimental hematoma, and the activation of N-methyl-D-aspartate (NMDA) receptors by glutamate can result in an influx of calcium and neuronal death in cases of intracerebral hemorrhage (ICH). Memantine, which is known to be a moderate-affinity, uncompetitive, NMDA receptor antagonist, was investigated with regard to its ability to block the glutamate overstimulation and tissue plasminogen activator (tPA)/urokinase plasminogen activator (uPA)/matrix metalloproteinase (MMP)-9 modulation in experimental ICH. Intracerebral hemorrhage was induced via the infusion of collagenase into the left basal ganglia of adult rats. Either memantine (20 mg/kg/day) or PBS was intraperitoneally administered 30 min after the induction of ICH, and, at daily intervals afterwards, for either 3 or 14 days. Hemorrhage volume decreased by 47% in the memantine group, as compared with the ICH-only group. In the memantine group, the numbers of TUNEL+, myeloperoxidase (MPO)+, and OX42+ cells decreased in the periphery of the hematoma. Memantine resulted in an upregulation of bcl-2 expression and an inhibition of caspase-3 activation. Memantine also exerted a profound inhibitory effect on the upregulation of tPA/uPA mRNA, and finally decreased the MMP-9 level in the hemorrhagic brain. In modified limb-placing test, the memantine-treated rats exhibited lower scores initially, and recovered more quickly and thoroughly throughout the 35 days of the study. Here, we show that memantine causes a reduction of hematoma expansion, coupled with an inhibitory effect on the tPA/uPA and MMP-9 level. Subsequently, memantine was found to reduce inflammatory infiltration and apoptosis, and was also determined to induce functional recovery after ICH.

Latest advances in intracerebral hemorrhage

Despite the fact that intracerebral hemorrhage (ICH) is the deadliest and least treatable of all stroke subtypes, historically researchers have directed most of their efforts toward ischemic strokes. However in the past few years this tendency has been changing, and several studies are showing very interesting results that allow us to believe that in the following years ICH management will change dramatically, paralleling the recent revolution that ischemic stroke treatment experienced in the past decade. Studies offering a better understanding of risk factors, pathophysiology, and treatment will help in primary and secondary prevention and also in developing therapeutic strategies to reduce brain damage. This review comments on some of the most relevant publications during the past year in any field related to ICH.

Modern treatment options for intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a devastating neurological event with a 30-day mortality of approximately 40%. Recent research provides new insights into the pathophysiology of ICH-associated edema, with potential molecular and cellular targets for future therapy. Neuroimaging techniques such as gradient echo MRI are yielding insights into cerebral microbleeds and the microangiopathies associated with hypertension and cerebral amyloid angiopathy. Recent literature provides new medical treatment strategies for fever, acute hypertension, and perihematomal edema, and methods of reducing intracranial pressure. Two randomized controlled trials have provided crucial evidence regarding surgical and medical intervention for acute ICH intervention. Recombinant factor VIIa appears to lessen growth of ICH when administered within 4 hours of ictus. Further study of potential efficacy and safety is underway in an international phase III trial. In addition, the Surgical Trial in Intracerebral Hemorrhage reported results from an international randomized trial of 1033 patients who did not show benefit for surgical evacuation of ICH, compared with medical therapy alone. Less invasive surgical methods for hematoma evacuation, studied previously over the past decade, continue to be investigated.

Location characteristics of early perihaematomal oedema

BACKGROUND

The natural history and triggers of perihaematomal oedema (PHO) remain poorly understood. Cerebral amyloid angiopathy (a common cause of lobar haemorrhage) has localised anticoagulant and thrombolytic properties, which may influence PHO. We hypothesised that early (within 24 hours) oedema to haematoma volume ratios are smaller in patients with lobar intracerebral haemorrhage (ICH) than in patients with deep ICH.

METHODS

Haematoma and PHO volumes were measured in consecutive patients admitted to an acute stroke unit with a diagnosis of spontaneous supratentorial ICH proven by computed tomography. The oedema to haematoma volume ratios were calculated and compared in patients with lobar ICH and deep ICH.

RESULTS

In total, 44 patients with ICH were studied: 19 patients had deep ICH, median haematoma volume 8.4 ml (interquartile range (IQR) 4.8 to 20.8), median PHO 8.2 ml (2.8 to 16), and 25 had lobar ICHs, median haematoma volume 17.6 ml (6.6 to 33.1) and median oedema volume 10.2 ml (3.4 to 24.2). Patients with lobar ICH were older than those with deep ICH (65.7 v 57.4 years, p = 0.009) but ICH location did not differ by sex or race. There was no evidence that haematoma or oedema volumes were related to type of ICH (p = 0.23, p = 0.39 respectively). The median oedema to haematoma volume ratios were similar in patients with lobar and deep ICH (0.67 v 0.58, p = 0.71). Controlling for age, sex, and race made little difference to these comparisons.

CONCLUSIONS

There are no major location specific differences in PHO volumes within 24 hours of ICH onset. Deep and lobar ICH may have common therapeutic targets to reduce early PHO.

Mechanisms of brain injury after intracerebral haemorrhage

The past decade has resulted in a rapid increase in knowledge of mechanisms underlying brain injury induced by intracerebral haemorrhage (ICH). Animal studies have suggested roles for clot-derived factors and the initial physical trauma and mass effect as a result of haemorrhage. The coagulation cascade (especially thrombin), haemoglobin breakdown products, and inflammation all play a part in ICH-induced injury and could provide new therapeutic targets. Human imaging has shown that many ICH continue to expand after the initial ictus. Rebleeding soon after the initial haemorrhage is common and forms the basis of a current clinical trial using factor VIIa to prevent rebleeding. However, questions about mechanisms of injuries remain. There are conflicting data on the role of ischaemia in ICH and there is uncertainty over the role of clot removal in ICH therapy. The next decade should bring further information about the underlying mechanisms of ICH-induced brain injury and new therapeutic interventions for this severe form of stroke. This review addresses our current understanding of the mechanisms underlying ICH-induced brain injury.

Third ventricle midline shift due to spontaneous supratentorial intracerebral hemorrhage evaluated by transcranial color-coded sonography

OBJECTIVE

We aimed to assess the clinical usefulness of the third ventricle midline shift (MLS) evaluated by transcranial color-coded sonography (TCCS) in acute spontaneous supratentorial intracerebral hemorrhage (ICH).

METHODS

Consecutive patients with acute (<24 hours after symptom onset) ICH were recruited for this TCCS study. Sonographic measurement of MLS and the pulsatility index (PI) of the middle cerebral arteries were compared with head computed tomographic (CT) data, including MLS, and hematoma volume. Poor functional outcome at 30 days after stroke onset was defined as modified Rankin scale greater than 2.

RESULTS

There were 51 patients with spontaneous supratentorial ICH who received CT and TCCS studies within a 12-hour window. Correlation between MLS by TCCS (mean +/- SD, 3.2 +/- 2.6 mm) and CT (3.0 +/- 2.4 mm) was high (gamma = 0.91; P < .01). There was also a good linear correlation between hematoma volume and MLS by TCCS (gamma = 0.81; P < .01). Compared with ICH volume less than 25 mL, those with greater volume had more severe MLS and a higher PI of the ipsilateral middle cerebral artery (P < .001). Midline shift by TCCS was more sensitive and specific than the PI in detecting large ICH (accuracy = 0.82 if MLS > or = 2.5 mm), and it was also a significant predictor of poor outcome (odds ratio, 2.09 by 1-mm increase; 95% confidence interval, 1.06-4.13).

CONCLUSIONS

Midline shift may be measured reliably by TCCS in spontaneous supratentorial ICH. Our study also showed that MLS on TCCS is a useful and convenient method to identify patients with large ICH and hematoma expansion and to predict short-term functional outcome.

Serum glial fibrillary acidic protein as a biomarker for intracerebral haemorrhage in patients with acute stroke

BACKGROUND

Biomarkers of stroke are an evolving field of clinical research. A serum marker which can differentiate between haemorrhagic and ischaemic stroke in the very early phase would help to optimise acute stroke management.

OBJECTIVE

To examine whether serum glial fibrillary acidic protein (GFAP) identifies intracerebral haemorrhage (ICH) in acute stroke patients.

METHODS

A pilot study assessing 135 stroke patients admitted within six hours after symptom onset. Diagnosis of ICH (n = 42) or ischaemic stroke (n = 93) was based on brain imaging. GFAP was determined from venous blood samples obtained immediately after admission, using a research immunoassay.

RESULTS

GFAP was detectable in the serum of 39 patients (34 of 42 (81%) with ICH, and five of 93 (5%) with ischaemic stroke). Serum GFAP was substantially raised in patients with ICH (median 11 ng/l, range 0 to 3096 ng/l) compared with patients with ischaemic stroke (median 0 ng/l, range 0 to 14 ng/l, p<0.001). Using receiver operating characteristic curve analysis, a cut off point of 2.9 ng/l provided a sensitivity of 0.79 and a specificity of 0.98 for the identification of ICH in acute stroke (positive predictive value 0.94, negative predictive value 0.91; p<0.001).

CONCLUSIONS

Serum GFAP can reliably detect ICH in the acute phase of stroke. Further evaluation of the usefulness of GFAP as an early diagnostic marker of ICH is now required, with the aim of optimising cause specific emergency management.

Blood pressure management during acute ischaemic stroke

Control of hypertension is a well-established goal of primary stroke prevention. Management of blood pressure in patients during acute ischaemic stroke, however, is complicated by the need to maintain brain perfusion. Lowering blood pressure in the acute setting may avoid the deleterious effects of high blood pressure but may also lead to cerebral hypoperfusion and worsening of the ischaemic stroke. Little information is available from clinical trials concerning optimal blood pressure management in acute stroke. Current protocols of thrombolytic therapy require strict blood pressure control below certain prescribed limits; however, in most acute stroke patients not treated with thrombolysis, blood pressure reduction is not routinely recommended and guidelines for target blood pressures are difficult to justify. Preliminary studies, in fact, suggest that there may be a role for blood pressure elevation in the treatment of some patients with acute ischaemic stroke.

Treatment of acute intracerebral hemorrhage with epsilon-aminocaproic acid: a pilot study

INTRODUCTION

Up to 40% of primary intracerebral hemorrhages (ICHs) expand within the first 24 hours (natural history). The authors aimed to study the safety and preliminary efficacy of epsilon-aminocaproic acid (EACA) in halting ICH enlargement.

METHODS

Consecutive patients with hematoma volumes ranging from 5 to 80 mL were recruited within 12 hours of ICH onset. A total of 5 g EACA was infused during 1 hour and then 1 g/hour for 23 hours. Hematoma volume was compared on baseline, and 24-48-hour brain imaging. Consecutive untreated patients underwent the same imaging protocol.

RESULTS

Three of the first five patients treated had HE>33% of their baseline volume. HE occurred in two of the nine untreated patients. The 80% confidence interval for HE in the treated patients was 32-88%. No thrombotic or other serious adverse events were attributed to EACA.

CONCLUSION

It is unlikely that the rate of HE in patients given EACA within 12 hours of ICH is less than the natural history rate, although this treatment appears to be safe.

Expansion in intracerebral hematoma

Intracerebral hemorrhage (ICH) is the last stroke subtype without a primary therapy. The major research question is whether to treat the whole chain of disease events or just stabilize one link in the process. Several candidate events that would benefit from treatment exist: hemorrhage extension, mass effect-clot removal, or delayed edema-inflammation. In this issue of Neurocritical Care, Piriyawat et al. present a pilot study using two convenience samples of ICH patients exploring the idea that blood clot stabilization with antifibrinolytic drugs would limit the early expansion of hematomas. Two groups of patients were studied in sequence: nine ICH patients who experienced two episodes of hematoma expansion (HE) served as controls, demonstrating a baseline hematoma extension event rate of 22%. A second group of five ICH patients was treated in the first 12 hours after symptoms with the antifibrinolytic drug e-aminocaproic acid. Three of the treated patients experienced HE for an event rate of 60%. On first pass, it seems that clot stabilization is not likely to occur with eanimocaproic acid. The author's institutional IRB concluded that treatment in this protocol was futile and requested the study be stopped.

Early hemostatic therapy using recombinant factor VIIa in a collagenase-induced intracerebral hemorrhage model in rats

Neurological deterioration during the first day after intracerebral hemorrhage (ICH) is associated with early hematoma growth in 18 to 38% of patients. While clinical studies continue to evaluate efficacy of activated recombinant factor VII (rFVlla) for reducing frequency of early hematoma growth, there have been no studies investigating the effect of rFVIIa on early hematoma growth. We used a collagenase-induced ICH model in the rat to evaluate the effects of rFVIIa on early hematoma growth. Two hours after injection of 0.14 U of type IV bacterial collagenase in 10 microL of saline into the basal ganglia, a small amount of blood collected in the striatum. The ICH gradually increased in size, extending posteriorly to the thalamus by 24 hours after injection. Intravenous administration of rFVIIa immediately after collagenase injection decreased average hematoma volume at 24 hours compared with vehicle-treated group (168.1 +/- 13.4 mm3 vs. 118.3 +/- 23.0 mm3, p < 0.01). There was also a decrease in total hemoglobin content in rats treated with rFVlla compared with vehicle-treated rats (optical density at 550 nm: 0.87 +/- 0.08 vs. 0.71 +/- 0.09, p < 0.05). There was no difference in cortical brain water content overlying the hematoma between the rFVlla- and vehicle-treated groups (81.4 +/- 0.7% vs. 81.7 +/- 0.4%). Our study indicates that treatment with rFVIla may be useful in reducing the frequency of early hematoma growth in ICH patients.

Spontaneous intracerebral hemorrhage in humans: hematoma enlargement, clot lysis, and brain edema

Early hematoma enlargement and delayed clot lysis contribute to brain injury after intracerebral hemorrhage (ICH). We investigated hematoma growth, clot lysis, and brain edema formation in patients with spontaneous ICH. A total of 17 spontaneous ICH patients who received regular medication were chosen for this study. All patients had their first CT scan within 5 hours of onset of symptoms (day 0). The patients then underwent second, third, and fourth CT scans at 1, 3, and 10 days later. Hematoma size and absolute and relative brain edema volumes were measured. Hematoma enlargement was defined as a > 33% increase in volume. Relative brain edema volume = absolute brain edema volume/hematoma size. Hematoma enlargement occurred in 4 of the 17 ICH patients (24%) within the first 24 hours. The hematoma sizes were reduced significantly at day 10 (p < 0.05) because of clot lysis. However, both absolute and relative brain edema increased gradually with time (p < 0.01). These results suggest that delayed brain edema following ICH may result from hematoma lysis. This study also shows that early hematoma enlargement occurs in Chinese patients with ICH. Reducing early hematoma growth and limiting clot lysis-induced brain toxicity could be potential therapies for ICH.

Ultra-early Hemostatic Therapy for Acute Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the least treatable form of stroke, and causes high mortality, severe disability, and a staggering economic burden. ICH accounts for 15% of stroke cases in the United States and Europe, and up to 30% in Asian populations. Computed tomography-based studies suggest that ICH growth within the first few hours of onset is common, and the principal cause of early neurological deterioration. Hematoma volume is also a well-established predictor of 30-day mortality. Intervention with ultra-early hemostatic therapy could minimize or prevent this early dynamic bleeding process, and might improve outcome. Recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) is approved for the treatment of bleeding in patients with hemophilia and inhibitors, but it may also promote hemostasis in patients with normal coagulation by acting locally at the bleeding site without activation of systemic coagulation. In a randomized, double-blind, placebo-controlled trial of 399 ICH patients treated with a single dose of 40, 80, or 160 microg/kg of rFVIIa or placebo within 4 hours of onset, subsequent hematoma growth was reduced by approximately 50% with rFVIIa. This was associated with a significant reduction (38%) in mortality, and improved functional outcomes among survivors. A phase III trial comparing 20 and 80 microg/kg rFVIIa with placebo is now in progress to confirm these results.

Recombinant activated factor VII and the anaesthetist

Recombinant activated factor VII is a safe and effective for the treatment and prevention of haemorrhage in haemophiliacs with circulating inhibitors to replacement factors, and patients with Glanzmann's thrombasthenia refractory to platelet transfusion. By restoring thrombin generation on the surface of tissue factor bearing cells, such as activated platelets and monocytes, recombinant activated factor VII has the potential to effect haemostasis in the setting of many coagulopathic states encountered by the anaesthetist in the operating theatre or the intensive care unit. Case reports of successful rescue therapy make up the majority of the literature covering other, numerous, off-label uses of recombinant activated factor VII, although some randomised, controlled studies, mostly underpowered to address safety concerns, have been performed. However, off-label use is becoming increasingly popular judging by the number of published case reports. Additional randomised, controlled trials to determine the safe and appropriate use of this potentially valuable therapy in broader patient groups are eagerly awaited.

Frameless stereotactic aspiration and thrombolysis of deep intracerebral hemorrhage is associated with reduction of hemorrhage volume and neurological improvement

INTRODUCTION

This is a phase-2 safety trial to demonstrate the ability of frameless stereotactic aspiration and thrombolysis of ICH to safely remove blood.

METHODS

Patients with ICH in the deep basal ganglia and internal capsule of > 5 cc volume were consented to undergo computed tomographic imaging for frameless stereotactic guidance registration. Using the frameless stereotactic (CT) guidance, a 4-mm diameter catheter was inserted into the body of the hematoma using a frontal burr hole approach. The catheter was aspirated and then flushed with saline and aspirated to remove unclotted blood. After a confirmatory CT scan to localize the catheter, 1 mg of recombinant tissue plasminogen activator (t-PA) was infused into the clot, permitted to bathe the clot for 30 minutes, and then drained into a closed circuit collection system. t-PA was infused every 8 hours for 48 hours. A follow up CT scan was obtained at 48 hours.

RESULTS

28 patients with ICH (mean age 67.1) were admitted and underwent the procedure. Mean initial ICH volume was 54.6 cc +/-6 37.8. Mean time from onset to aspiration was 44 hours (range 7-180). Mean initial NIH Stroke scale (NIHSS) score was 24 (range 15-33). Compared with initial CT scan, there was a mean reduction of ICH volume by 77 +/-6 13% on final CT scan (p < 0.0002). Compared with initial NIHSS, the discharge mean NIHSS (16 +/- 6) was significantly improved (p < 0.001). There were no infectious, hemodynamic or neurologic complications. There were no episodes of symptomatic hemorrhagic enlargement and one case of asymptomatic bleeding along the catheter tract.

CONCLUSION

Frameless stereotactic aspiration and thrombolysis (FAST) of deep spontaneous intracerebral hemorrhage is a safe therapy that is associated with reduction in ICH volume, early improvement in NIHSS and potentially could be used to improve outcome.

Benefits of adapting minimal invasive techniques to selected patients with spontaneous supratentorial intracerebral hematomas

OBJECTIVES

This study assesses the benefits of adapting minimal invasive techniques (MIT) to selected patients with spontaneous supratentorial intracerebral hematomas (SSICHs).

METHODS

The study compares the post-operative residual clot volume and clinical outcome of 89 selected, MIT evacuated SSICH-patients to those of 138 unselected cases operated in our department. Selection criteria includes patient age, early admission and MIT treatment. MIT treatment included: 28 patients with deep SSICHs smaller than 30 cm3 associated with intraventricular bleeding who underwent neuronavigation-guided stereotactic catheter lysis, 37 patients with deep hematomas larger than 30 cm3 and 24 patients with a lobar hemorrhage compressing eloquent regions who underwent microsurgical (endoscopic or neuronavigation assisted) clot aspiration.

RESULTS

In eight (9%) of the patients in the MIT group, the CT scan control showed a residual clot smaller than 30% of the initial hemorrhage. The neurological condition 3 months later revealed 24 (26.9%) of these patients having a severe disability and 46 (51.6%) patients independent or slightly disabled. Nineteen patients (21.9%) died or remained vegetative. In the control group, 48 (34.7%) cases showed residual clots (<30%). Sixty-two (44.9%) patients of this group were severely disabled and only 40 (28.9%) were independent. Thirty-six (26%) patients died or were vegetative. There was a p<0.001 significant difference in volume of residual clots as well as p<0.01 for the outcome between the two groups.

CONCLUSIONS

Adapting minimally invasive techniques to case selection improves the effectiveness of clot removal and the outcome of the patients with SSICHs.

Treatment of intracerebral haemorrhage

Apart from management in a specialised stroke or neurological intensive care unit, until very recently no specific therapies improved outcome after intracerebral haemorrhage (ICH). In a recent phase II trial, recombinant activated factor VII (eptacog alfa) reduced haematoma expansion, mortality, and disability when given within 4 h of ICH onset; a phase III trial (the FAST trial) is now in progress. Ventilatory support, blood-pressure reduction, intracranial-pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in intensive care units. Ventricular drainage should be considered in all stuporous or comatose patients with intraventricular haemorrhage and acute hydrocephalus. Given the lack of benefit seen in a the recent STICH trial, emergency surgical evacuation within 72 h of onset should be reserved for patients with large (>3 cm) cerebellar haemorrhages, or those with large lobar haemorrhages, substantial mass effect, and rapidly deteriorating condition.

Recent advances in the management of acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is the most deadly form of stroke, and its acute treatment has suffered from a lack of guidance by reliable clinical trial data. In the past year, however, important clinical trials have helped point toward effective acute management. Studies have shown that magnetic resonance imaging is as accurate as computed tomography in diagnosing acute ICH, although this study is not always feasible in critically ill patients. Ultra-early hemostatic therapy has shown promise in limiting early hematoma expansion and rebleeding. The role of early surgery in patient management has been partially clarified. Finally, a novel treatment for intraventricular hemorrhage has shown promise in speeding clot resolution. All of these advances provide grounds for optimism that multimodal, evidence-based treatment of acute ICH will be reality in the near future.

Intracerebral Hemorrhage

INTRODUCTION

Intracerebral hemorrhage (ICH) occurs from the rupture of small vessels into the brain parenchyma and accounts for approximately 10% of all strokes in the United States, and carries with it a significantly high morbidity and mortality.

SUMMARY

This article reviews the course and management of ICH. The most common chronic vascular diseases that lead to ICH are chronic hypertension and cerebral amyloid angiopathy. Additional factors that predispose to ICH include vascular malformations, chronic alcohol use, hypocholesterolemia, and use of anticoagulant medications. The understanding of mechanisms leading to ICH has advanced significantly, but questions regarding site predilection and timing of spontaneous hemorrhage still remain. Management in the acute setting is first focused on reducing hematoma expansion. Although no specific therapy has yet been proven effective, promising agents, particularly recombinant Factor VIIa, are on the horizon. Subsequent care is focused on controlling hemostasis, hemodynamics, and intracranial pressure in efforts to minimize secondary brain injury.

CONCLUSION

The morbidity and mortality associated with ICH remain high despite recent advances in our understanding of the clinical course of ICH. Novel preventive and acute treatment therapies are needed and may be on the horizon.

Severe Hypertension in the Emergency Department Patient

Severely elevated blood pressure is a common clinical problem en-countered in the Emergency Department. It is often difficult for physicians to differentiate between patients who need emergent blood pressure reduction, requiring the use of intravenous agents and in-tensive monitoring, and those for whom careful, slow reduction in BP is more appropriate. The optimal assessment and management of these patients is reviewed here, with an emphasis on clinical strategies that will most efficiently identify those at greatest risk.

Is emergent anti-hypertensive treatment beneficial in intracranial hemorrhage?

A retrospective chart review of adult patients with primary intracranial hemorrhage (ICH) was conducted to determine the effects of emergent anti-hypertensives on mortality. Data included mean arterial pressure (MAP), Glascow Coma Scale score (GCS), ICH size, and anti-hypertensive treatment. Multi-variable logistic regression determined the effect of anti-hypertensives on ICH mortality. Of 66 patients studied, the overall mortality was 30.3%. Mortality was 34.5% for patients initially treated with anti-hypertensives vs. 25.8% for patients not treated. After controlling for age, MAP, GCS, and ICH size, anti-hypertensives given within the first 6 h of presentation were associated with a reduction in mortality with a p value of 0.0375 and an odds ratio of 140 (95% confidence interval [CI] 1.332 to >999). However, this effect may not occur in patients presenting with a systolic blood pressure (SBP)<200 mm Hg. In conclusion, in patients with primary intracranial hemorrhage, there was a significant decrease in mortality associated with emergent anti-hypertensive therapy. A larger prospective study is needed to confirm these findings, define the subgroups that may benefit, and better determine the effect size.

Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage

BACKGROUND

Warfarin increases mortality of intracerebral hemorrhage (ICH). The authors investigated whether this effect reflects increased baseline ICH volume at presentation or increased ICH expansion.

METHODS

Subjects were drawn from an ongoing prospective cohort study of ICH outcome. The effect of warfarin on baseline ICH volume was studied in 183 consecutive cases of supratentorial ICH age > or = 18 years admitted to the emergency department over a 5-year period. Baseline ICH volume was determined using computerized volumetric analysis. The effect of warfarin on ICH expansion (increase in volume > or = 33% of baseline) was analyzed in 70 consecutive cases in whom ICH volumes were measured on all subsequent CT scans up to 7 days after admission. Multivariable analysis was used to determine warfarin's influence on baseline ICH, ICH expansion, and whether warfarin's effect on ICH mortality was dependent on baseline volume or subsequent expansion.

RESULTS

There was no effect of warfarin on initial volume. Predictors of larger baseline volume were hyperglycemia (p < 0.0001) and lobar hemorrhage (p < 0.0001). Warfarin patients were at increased risk of death, even when controlling for ICH volume at presentation. Warfarin was the sole predictor of expansion (OR 6.2, 95% CI 1.7 to 22.9) and expansion in warfarin patients was detected later in the hospital course compared with non-warfarin patients (p < 0.001). ICH expansion showed a trend toward increased mortality (OR 3.5, 95% CI 0.7 to 8.9, p = 0.14) and reduced the marginal effect of warfarin on ICH mortality.

CONCLUSIONS

Warfarin did not increase ICH volume at presentation but did raise the risk of in-hospital hematoma expansion. This expansion appears to mediate part of warfarin's effect on ICH mortality.

A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage

The authors performed a multicenter prospective observational study to evaluate the feasibility and safety of intravenous antihypertensive protocol for acute hypertension in patients with intracerebral hemorrhage (ICH). Twenty-seven patients with ICH and acute hypertension (mean age 61.37 +/- 14.27; 10 were men) were treated to maintain the systolic blood pressure (BP) below 160 mm Hg and diastolic BP below 90 mm Hg within 24 hours of symptom onset. Neurological deterioration (defined as a decrease in initial Glasgow Coma Scale score > or = 2) was observed in 2 (7.4%) of 27 patients during treatment. Among patients who underwent follow-up computed tomography, hematoma expansion (more than 33% increase in hematoma size at 24 hours) was observed in 2 (9.1%) of 22 patients. Patients treated within 6 hours of symptom onset were more likely to be functionally independent (modified Rankin scale < or = 2) at 1 month compared with patients who were treated between 6 and 24 hours (8 of 18 versus 0 of 9,P = .03). Aggressive pharmacological treatment of acute hypertension in patients with ICH can be initiated early with a low rate of neurological deterioration and hematoma expansion.

Recombinant FVIIa in the management of intracerebral haemorrhage in severe thrombocytopenia unresponsive to platelet-enhancing treatment

Intracranial haemorrhage (ICH) is a dramatic and potentially life-threatening presentation of children with thrombocytopenia. Management is limited to supportive care. Recent evidence suggests that ongoing bleeding following the initial ICH may result in greater neurological morbidity and mortality. Haemostatic agents, including recombinant factor VIIa (rFVIIa), a product licensed for use in patients with haemophilia and inhibitors, may be helpful in reducing bleeding in children with refractory thrombocytopenia. We present the case of a 16-year-old girl with severe refractory immune thrombocytopenia, who presented with a major ICH and responded to treatment that included rFVIIa and platelet transfusions. The dose of rFVIIa was empirically chosen and based on reported cases in the literature. The case highlights a number of issues regarding off-label use of rFVIIa and demonstrates the need to prospectively collect accurate information on the off-label use of this new potentially useful medication.

Emerging medical and surgical management strategies in the evaluation and treatment of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) accounts for approximately 10% of all strokes and causes high morbidity and mortality. Rupture of the small perforating vessels of the cerebral arteries is caused by chronic hypertension, which induces pathologic changes in the small vessels and accounts for most cases of ICH; however, amyloid angiopathy and other secondary causes are being seen more frequently with the increasing age of the population. Recent computed tomographic studies have revealed that ICH is a dynamic process with up to one third of initial hemorrhages expanding within the first several hours of ictus. Secondary injury is believed to result from the development of cerebral edema and the release of specific neurotoxins associated with the breakdown products of hemoglobin. Treatment is primarily supportive. Surgical evacuation is the treatment of choice for patients with neurologic deterioration from infratentorial hematomas. Randomized trials comparing surgical evacuation to medical management have shown no benefit of surgical removal of supratentorial hemorrhages. New strategies focusing on early hemostasis, improved critical care management, and less invasive surgical techniques for clot evacuation are promising to decrease secondary neurologic injury. We review the pathophysiology of ICH, its medical management, and new treatment strategies for improving patient outcome.

Recombinant activated factor VII for acute intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage is the least treatable form of stroke and is associated with high mortality. Among patients who undergo computed tomography (CT) within three hours after the onset of intracerebral hemorrhage, one third have an increase in the volume of the hematoma related to subsequent bleeding. We sought to determine whether recombinant activated factor VII (rFVIIa) can reduce hematoma growth after intracerebral hemorrhage.

METHODS

We randomly assigned 399 patients with intracerebral hemorrhage diagnosed by CT within three hours after onset to receive placebo (96 patients) or 40 microg of rFVIIa per kilogram of body weight (108 patients), 80 microg per kilogram (92 patients), or 160 microg per kilogram (103 patients) within one hour after the baseline scan. The primary outcome measure was the percent change in the volume of the intracerebral hemorrhage at 24 hours. Clinical outcomes were assessed at 90 days.

RESULTS

Hematoma volume increased more in the placebo group than in the rFVIIa groups. The mean increase was 29 percent in the placebo group, as compared with 16 percent, 14 percent, and 11 percent in the groups given 40 microg, 80 microg, and 160 microg of rFVIIa per kilogram, respectively (P=0.01 for the comparison of the three rFVIIa groups with the placebo group). Growth in the volume of intracerebral hemorrhage was reduced by 3.3 ml, 4.5 ml, and 5.8 ml in the three treatment groups, as compared with that in the placebo group (P=0.01). Sixty-nine percent of placebo-treated patients died or were severely disabled (as defined by a modified Rankin Scale score of 4 to 6), as compared with 55 percent, 49 percent, and 54 percent of the patients who were given 40, 80, and 160 microg of rFVIIa, respectively (P=0.004 for the comparison of the three rFVIIa groups with the placebo group). Mortality at 90 days was 29 percent for patients who received placebo, as compared with 18 percent in the three rFVIIa groups combined (P=0.02). Serious thromboembolic adverse events, mainly myocardial or cerebral infarction, occurred in 7 percent of rFVIIa-treated patients, as compared with 2 percent of those given placebo (P=0.12).

CONCLUSIONS

Treatment with rFVIIa within four hours after the onset of intracerebral hemorrhage limits the growth of the hematoma, reduces mortality, and improves functional outcomes at 90 days, despite a small increase in the frequency of thromboembolic adverse events.

Thrombocytopenia Predicts Progressive Hemorrhage after Head Trauma

Patients with traumatic brain injury (TBI) often show progression of hemorrhagic injuries (PHI) after admission to the hospital. This progression is correlated with poor outcome. In this study, we have investigated if thrombocytopenia was a risk factor for PHI. The study was performed on patients admitted to the hospital with severe TBI during year 2000. In total, 50 patients were admitted with severe TBI. Twenty-seven out of these had complete platelet counts at admission and 24 hours thereafter and were included for further study. We found thrombocytopenia at admission to be a risk factor for PHI (p=0.008). We also found that the platelet count decreased more significantly during the first 24 h after injury in patients with PHI compared to patients without PHI (p=0.009). A trend towards longer periods of mechanical ventilation in patients with PHI compared to patients without PHI was identified. These findings support a causal relationship between thrombocytopenia and PHI. The findings provide a rationale for future studies of hemostatic agents in the treatment of TBI in order to minimise complications caused by PHI.

Acute changes in cortical excitability in the cortex contralateral to focal intracerebral hemorrhage in the swine

Injury to the cerebral cortex results in functional deficits not only within the vicinity of the lesion but also in remote brain regions sharing neuronal connections with the injured site. To understand the electrophysiological basis of this phenomenon, we evaluated the effects of a focal intracerebral hemorrhage (ICH) on cortical excitability in a remote, functionally connected brain region. Cortical excitability was assessed by measuring the somatic evoked potential (SEP) elicited by electrical stimulation of the swine snout, which is somatotopically represented in the rostrum area of the primary somatosensory (SI) cortex. The SEP was measured on the SI cortex ipsilateral to the site of ICH and on the contralateral SI cortex during the acute period (< or =11 h) after collagenase-induced ICH. The ICH rapidly attenuated the SEP on the ipsilateral cortex as we reported earlier. Interestingly, the ICH also attenuated the SEP on the contralateral SI cortex. Evoked potentials in the contralateral SI cortex showed a gradual decrease in amplitude during this acute period of ICH. We then investigated whether the interhemispheric connections shared by the contralateral SI and the lesion cortex were responsible for the diminished evoked potentials in the uninjured hemisphere after ICH. A separate group of animals underwent corpus callosal transection prior to electrocorticography (ECoG) recordings and ICH injury. Within hours of hemorrhagic injury, a gradual but marked increase in evoked potential amplitude was observed in the homotopic SI cortex of callosotomized animals as compared to pre-injection recordings. The enhancement suggests that there are additional effects of ICH on remote areas functionally connected to the site of injury. Functional deficits were present in both SI cortices within the first several hours of a unilateral injury indicating that the cessation of brain activity in the lesioned SI is mirrored in the contralateral hemisphere. This electrophysiological depression in the uninjured SI cortex is mediated in part by the interhemispheric connections of the corpus callosum.

Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage

INTRODUCTION

To test the feasibility and safety of a minimally invasive technique, we report our experience in treating spontaneous intracerebral hemorrhage (ICH) patients by using frameless stereotactic clot aspiration-thrombolysis and its effects on their 30-day survival. We compared the observed cohort mortality with its predicted 30-day ICH mortality, by using previously validated methods.

METHODS

Selection criteria were diagnosis of hypertensive ICH > or =35 cc, reduced level of consciousness, and no brainstem compression. Frameless stereotactic puncture/clot aspiration followed by intraclot external catheter placement was performed. Two milligrams of recombinant tissue plasminogen activator (rtPA) was administered q12 hours until ICH volume < or =10 cc, or the catheter fenestrations were no longer in continuity with the clot.

RESULTS

Fifteen patients were treated, mean age was 60.7 years. Hemorrhage locations included basal ganglia (13), thalamic (1), and lobar (1); mean systolic blood pressure; and admission ICH volumes were 229.3 mmHg and 59.1 cc, respectively. Median time from ictus to clot aspiration/thrombolysis was 1 (range 0-3) day. Mean hematoma volume was reduced to 17% of pretreatment size. Complications were ventriculitis (6.6%) and clot enlargement (13.3%). Two patients were dead at 30 days. Median Glasgow Coma Scale (GCS) scores were 10.5 (4-15) at admission and 11.0 (3-15) at discharge. By using the most conservative estimate for analysis, probability of observing two or fewer deaths among 15 patients with an overall probability of dying calculated at 0.33 was p = 0.079.

CONCLUSIONS

In this selected cohort of patients with ICH, stereotactic aspiration and thrombolytic washout seemed to be feasible and to have a trend towards improved 30-day survival, when using their predicted mortality data as "historical control." Complications did not exceed expected incidence rates. Based on the experience presented here as well as previous similar reports, a larger, randomized study addressing dose escalation, patient selection, and best therapeutic window is needed.

Brain tissue oxygen monitoring in intracerebral hemorrhage

INTRODUCTION

Brain tissue oxygen (PbrO2) monitoring is an emerging technique for detection of secondary brain injury in neurocritical care. Although it has been extensively reported in traumatic brain injury and aneurysmal subarachnoid hemorrhage, its use in nontraumatic intracerebral hemorrhage (ICH) has not been well described. We report complementary preliminary studies in a large animal model and in patients that demonstrate the feasibility of PbrO2 monitoring after ICH.

METHODS

To assess early events after ICH, Licox Clark-type oxygen probes were inserted in the bilateral frontal white matter of four anesthetized swine that subsequently underwent right parietal hematoma formation in an experimental model of ICH. Intracranial pressure (ICP) was monitored as well. Seven patients with acute ICH, who were undergoing ICP monitoring as part of standard neurocritical care, had placement of a frontal oxygen probe, with subsequent monitoring for up to 7 days.

RESULTS

In the swine ICH model, a rise in ICP early after hematoma formation was accompanied by a decrease in ipsilateral and contralateral PbrO2. Secondary increases in hematoma volume resulted in further decreases in PbrO2 over the first hour after ICH. In patients undergoing oxygen monitoring, low PbrO2 (<15 mmHg) was common. In these patients, changes in FiO2, mean arterial pressure, and cerebral perfusion pressure (but not ICP) predicted subsequent change in PbrO2.

CONCLUSION

Brain tissue oxygen monitoring is feasible in ICH patients, as well as in a swine model of ICH. Translational research that emphasizes complementary information derived from human and animal studies may yield additional insights not available from either alone.

Recombinant factor VIIa for rapid reversal of warfarin anticoagulation in acute intracranial hemorrhage

OBJECTIVE

To assess the effects of recombinant factor VIIa (rFVIIa) on hemorrhage volume and functional outcomes in warfarin-related acute intracranial hemorrhage (ICH), which has a 30-day mortality of more than 50%.

PATIENTS AND METHODS

We reviewed the clinical, laboratory, and radiographic features of a consecutive series of 7 patients (median age, 87 years; 5 women) with symptomatic, nontraumatic warfarin-related acute ICH treated with intravenous rFVIIa at St. Luke's Hospital in Jacksonville, Fla, between December 2002 and September 2003. Prestroke baseline functional status was assessed with the modified Rankin Scale. Outcome was assessed with the Glasgow Outcome Scale.

RESULTS

The international normalized ratio decreased from a mean of 2.7 before administration of rFVIIa to 1.08 after administration of rFVIIa. The median prestroke score on the modified Rankin Scale was zero. The median presenting score on the Glasgow Coma Scale was 14 (range, 4-15). The mean time from onset to treatment was 6.2 hours. The mean initial dose of rFVIIa was 62.1 microg/kg. One patient underwent placement of an external ventricular drain, and another underwent craniotomy and hematoma evacuation. Five of the 7 patients survived and were dismissed from the hospital with severe disability (Glasgow Outcome Scale, 3); 2 patients died during hospitalization.

CONCLUSIONS

Intravenous bolus administration of rFVIIa can rapidly lower the international normalized ratio and appears to be safe for patients with warfarin-related ICH. Prospective controlled studies are needed to determine whether rFVIIa can prevent hematoma expansion and improve neurologic outcomes in patients with warfarin-related ICH.