Patient First - Hemorrhagic Stroke (SAH/ICH)

Question 1

What is a Hemorrhagic Stroke?

Answer 1

Hemorrhagic stroke: one type of stroke caused by spontaneous brain bleed (i.e., non-traumatic). It accounts for 20% of stroke; the rest 80% is ischemic stroke.

NOTE: What you hear about ‘code stroke’, tPA/TNK, thrombectomy. It is for ischemic stroke, NOT hemorrhagic stroke

Question 2

What is SAH?

Answer 2

Aneurysmal Subarachnoid Hemorrhage (SAH)

One type of hemorrhagic stroke caused by the rupture of cerebral aneurysm. Patients with high Hunt & Hess Scale are at highest risk of seizure, but are typically comatose/sedated/intubated

Question 3

What is ICH?

Answer 3

Intracerebral Hemorrhage (ICH)

Another type of hemorrhagic stroke caused by bleeding within the brain tissue itself. High blood pressure (hypertension) can cause these thin-walled arteries to rupture, releasing blood into the brain tissue.

You may hear ‘Code ICH’, which is an on-going nation-wide initiative for early diagnosis and treatment of ICH

Question 4

Describe a Neurological Exam for SAH/ICH patients

Answer 4

SAH/ICH patients undergo Q1 (i.e., hourly) neurological exam, typically performed by neuro critical care nurses. Seizure monitoring is part of the Q1 exam routine.

Question 5

What are the ASA/AHA (American Stroke Assoc. + American Heart Assoc.) guidelines for ICH? What year were they released?

Answer 5

“In patients with Spontaneous ICH and unexplained abnormal or fluctuating mental status or suspicion of seizures, continuous EEEG is reasonable to diagnose electrographiuc seizures and epileptiform discharges”

2022

Question 6

What are the ASA/AHA (American Stroke Assoc. + American Heart Assoc.) guidelines for SAH? What year were they released?

Answer 6

“In patients with aSAH and either fluctuating neurological exam, depressed mental state, ruptured MCA aneurysm, high grade SAH, ICH, hydocephalus, or cortical infarction, ccEEG is reasonable to detect seizures”

2023

Question 7

What percent off aSAH patients experience seizures?

Answer 7

up to 15.2% of aneurysmal SAH patients

Question 8

What is the relationship b/w 1 hour of seizure after aSAH and increase in disability/mortality?

Answer 8

Every 1 hour off seizure on EEG after aSAH = 10% relative increase in odds of 3-month disability and mortality

Question 9

What % of spontaneous ICH patients experience non-convulsive seizure?

Answer 9

up to 28%. Majority of seizures were non-convulsive in the first 72h after ICH in the PEACCH randomized controlled trial

Question 10

Electrographic seizures are associated with X# higher odds of poor outcomes after Lobar ICH?

Answer 10

5.47 higher odds off poor outcomes

Question 11

Objection Handling - “We don’t see seizure in ICH patients”

2 bullets

Answer 11

According to the PEACH trial, majority of seizures within 72hr after ACH were non-convulsive/electrographic only. Without EEG, it’s impossible to diagnose.

A study from Yale found that electrographic seizure predicts 5+ times increased odds of poor outcome in lobar ICH patients

Question 12

Objection Handling - “I already use seizure prophylaxis in all SAH/ICH patients”

1 Bullet

Answer 12

Provide 2023 and 2022 AHA/ASA Guidelines

In the recent guidelines from the American Heart Assoc. and American Stroke Assoc., prophylactic antiseizure medication is suggested as “Not beneficial” in ICH and aSAH patients. Rapid EEG could be a great way to guide the use of ASM

Question 13

Objection Handling - “We need long term monitoring in these patients”

2 bullets

Answer 13

Ensure you did discovery on patient volume. “Up to 28% of these patients have NCS. You saw X patients last month; did they all get continuous EEG quickly?”

Rapid EEG can help you prioritize continuous monitoring resources to those who are in the greatest needs