Management of Patients with Intracerebral Hemorrhage

In addition to our projects on AICML, we are involved with several projects that relate to management of intracerebral hemorrhage (ICH). The Emergency Medical Services (EMS) triage system in Chicago and many other cities, requires ambulances to transfer non-trauma patients to the nearest emergency department. Unfortunately, those with ICH often end up in urban or community hospitals without any acute neurological/neurosurgical services. The only economically feasible way to preferentially triage ICH patients to appropriate medical centers with acute neurological/neurosurgical services is to have a method to enhance the in-field detection of ICH. Our work on AICML detection (see above) is one approach to rectify this problem.While we are working on technology that can help with acute in-field detection of ICH, we have done important work defining the present state of ICH care in urban emergency and community departments without acute neurological/neurosurgical services. We did initial work defining delays in acute definitive management of ICH patients related to hospital-to-hospital transfers due to the initial triage of ICH patients to hospitals with inadequate neurological resources. As a follow-up to that foundational work, we developed a stroke triage survey tool. We have personally surveyed emergency doctors at key urban and community medical centers without acute neurological/neurosurgical services and asked them to identify their inadequacies in this clinical area, share their perceptions of the impact of their clinical limitations on ICH patient outcome, and their reflections on methods to better triage ICH patients. Doctors who work in these emergency departments plainly stated that patients highly suspected to have suffered ICH should not be sent to their hospitals, and that patients have suffered worse outcome (including death) because of their inability to acutely treat these patients. This work has been presented ata an international conference and serves as an important foundation for the exciting movement within the stroke community to change the approach to triage of stroke patients.

We have an interest in some of the readily detectable and modifiable factors that may contribute to ICH expansion. One of these factors is abnormal platelet function, and we have recently described a consecutive series of patients with platelet dysfunction in patient with acute ICH – many without known previously exposure to anti-platelet agents. This work has been formally presented and adds to a growing body of literature that promises to shed new insights into the potential role of acute platelet function screening in ICH patients and the role for restoration with medication and/or platelet transfusion.

We are involved with two of the most important prospective multi-center clincial trials on intracerebral hemorrhage funded by the NINDS, Clear IVH III and MISTIE (presently on hold for the development and funding of the next phase of the trial). The University of Chicago Medicine is the site of the lead neurosurgical principal investigator for the entire trial. Clear IVH III involves enrolling patients with ICH and/or intraventricular hemorrhage who require ventricular drains to be randomized to either intraventricular rt-PA (to facilitate clot dissolution and limit ventricular outflow obstruction) or placebo. MISTIE focused on testing the outcome benefit of sterotatically adminstered rt-PA into an ICH with subsequent clot aspiration. These clinical trials are pivotal and will clearly impact the future management of patients with ICH.