Intercranial hemorrhage - poisson Flashcards
Describe an epidural hemorrhage. What is characteristically seen on imaging? What is the primary cause?
Lenticular shape on CT imaging, most commonly a result of trauma. Generally assocated with a skull fracture. Middle meningeal artery is commonly involved. Medical emergency as rising ICP will cause a mass effect leading to rapid deterioration.
Describe subdural hemorrhage. What populations are typically affected? Is trauma involved? What vessels are disrupted. What is seen on imaging?
Venous bleed due to tearing of the “bridging veins.” Generally due to trauma. Imaging reveals concave, “banana” shaped. More common in elderly patients due to brain atrophy.
Subarachnoid hemorrhage. Where does it occur, and what are the most common causes?
What does it look like on imaging? What are the clinical symptoms? What is the mortality?
What classification system is used to grade SAH?
Hemorrhage into the space between the arachnoid mater and brain. 5% of strokes. Trauma is the most common cause, but aneurysm is the most common cause of non-traumatic SAH (80%).
Visualized as an “X “ or “star of death” on CT. This is the classic “worst headache of your life” after aneurysmal rupture. Sudden death in 1/3 of patients. 50-60% mortality.
Use the Hess and Hunt classification. (Grade 1-5, 5 is worst).
Intraparenchymal hemorrhage (ICP) aka Intracerebral hemorrhage (ICH)
Blood clots that cause hemorrhage directly into the brain tissue. Associated with HTN and AGE, commonly in the deep grey matter (Putamen, GP, Thalamus, Pons). Lobar ICH are less common, and often associated with a primary cause.
Around 10% of stroke is ICH or IPH. High morbidity and mortality (30-35% 5 day mortality). Can be associated with anticoagulation or a coagulation disease.
3 things that are bright on CT?
Bone, Blood, and Bling
Should patients with stroke-like symptoms take an aspirin on their way to the ED?
No. Even neurologists can struggle differentiating between a hemorrhagic vs ischemic stroke.
Most common locations for intracerebral hemorrhage:
Basal ganglia
Thalamus
Pons
Cerebellar
**Deep ICH are not well tolerated and have relatively poor outcomes. HTN is a big risk factor. Pontine hemorrhage “locked-in syndrome.”
Aneurysm 2 types. What are the most common location?
Saccular and Fusiform. Saccular aneurysm is the most common, and usually forms at branch points.
The anterior communicating artery and the posterior communicating artery are the most common spots for aneurysm in the circle of wilis. (Berry aneurysms)
Aneurysmal SAH. What is the clinical presentation
“Not usually subtle.” 50-60% Mortality. Extreme headache, can result in sudden death (33%).
What is the food mnemonic to differentiate between a subarachnoid hemorrhage and an intraparenchymal hemorrhage?
SAH = frosting drizzle over the bundt cake IPH = fruit pie
What is the clinical presentation of an ICH?
What differentiates this from an ischemic stroke?
Acute focal neurologic deficit, nausea, vomiting, decreased LOC.
??Perhaps the increased ICP leading to nausea/vomiting? most likely do not see increased ICP with an ischemic stroke.
If someone is diagnosed with Amyloid angiopathy, with what hemorrhagic event should physicians consider?
Lobar IPH. When stained with congo red and viewed under UV light, the amyloid will show up as “apple green birefringence.”
Patients get recurrent lobar hemorrhages that lead to progressive dementia and disability. Amyloid deposition is found in the vessels (intramural). This disorder is DIFFERENT from systemic amyloidosis
How might an intraparenchymal hematoma present clinically?
Begins with a mild headache, deficit, maybe some nausea, and progress over a few minutes to hours adding decreased level of consciousness. The family often will describe a hemiparesis steadily progressing into hemiplegia and a level of consciousness that steadily deteriorates into coma.
While this is generally a disease of HTN and age, younger patients on stimulants are at risk.
Above what size are aneurysms likely to rupture? Statistically, when is clinical intervention likely to outweight the risks of watchful waiting? Does this vary based on location in the brain?
Aneurysms are commonly seen in the ACA and the PCAs. PCAs rupture at smaller diameters, and the risk of rupture rises above 14% (5pyear) above 7mm.
ACA aneurysms tolerate larger sizes, and the 5 year risk rises above 14% for aneurysms greater than 12mm.
What is important to know about AVM (Arteriovenous malformation?)
AVM have a 3%/year chance of bleeding. Size of the defect does not predict severity. Can result in seizure disorders (hemispheres often look pretty bad on imaging). Intervention possible, but watchful waiting is common.
