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Acute Care II - Summer 2017 > ICH & SAH > Flashcards

ICH & SAH Flashcards

1
Q

intracranial hemorrhage

A

it’s an umbrella term including: subdural hematoma, epidural hematoma, intracerebral hematoma, subarachnoid hemorrhage

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2
Q

what’s the pacing of a subdural hematoma?

A

slow

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3
Q

what’s the pace of a epidural hematoma?

A

pretty quick, several hours lucid, the LOC, then goes quickly. the middle meningeal artery, once blood fills the space down you go,

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4
Q

what’s the leading cause of ICH?

A

trauma

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5
Q

what are the other causes of non-traumatic ICH

A

HTN, aneurysm, then AV malformation/other

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6
Q

primary causes of ICH?

A

HTN, cerebral amyloid angiopathy, drugs, coagulopathy

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7
Q

secondary causes of ICH

A

vascular malformation (AVM), moyamoya, hemorrhagic conversion-ischemic stroke, venous sinus thrombosis, tumor, cerebral vasculitis

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8
Q

what are pathological changes of HTN hemorrhage

A

micro aneurysms of the perforators (Charcot Bouchard Aneurysms) accelerated atherosclerosis large vessels

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9
Q

where in the brain do HTN bleeds happen

A
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10
Q

how do you manage ICH?

A

-blood pressure control -reversal of anti-coagulation -management of ICP -reducing secondary risks - identify etiology

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11
Q

BP control guidelines

A
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12
Q

how do you achieve hemostasis w/ warfarin

A
  1. vitamin K 10 mg IV x 1 2. Kcentra (weight & INR based) 3. FFP
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13
Q

hemostasis w/ antiplatelets

A
  1. platelet transfusion 2. dDAVP (clotting promoter)
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14
Q

hemostasis w/ direct thrombin inhibitors (dabigatran etc)

A
  1. activated prothrombin complex concentrate or 2. recombinant factor VII
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15
Q

hemostasis w/ novel oral anti-coagulation

A

activated prothrombin complex concentrate

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16
Q

what is Cushing’s triad

A

bradycardia, widening pulse pressure, irregular respirations

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17
Q

what is Monroe Kellie hypothesis

A

it states that the cranial compartment is incompressible and that the volume inside the cranium is fixed. The cranium and its constituents (blood, CSF, and brain tissue) create a state of volume equilibrium, such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another

18
Q

what is a cerebral arteriorveous malformation (AVM)

A

aberrant direct connections between the cerebral arterial and venous systems abnormal connection between arteries and veins bypassing capillary system

19
Q

common presenting symptoms of AVM

A

intracerebral hemorrhage seizure headache transient focal neurological deficits progressive focal neurologic deficits

20
Q

physiology of AVM

A

at least one fistula between arterial and venous circulation

21
Q

what does AVM look like?

A

has peppered appearance

22
Q

how do you grade an AVM?

A

using the Spetzler Martin AVM scale risk calculation surgery -size: < 3 cm, 3-6 cm, > 6 cm -eloquent area -venous drainage: superficial or deep

23
Q

treatment for AVM

A

-usually 2-6 week reset period -reimage vessels to determine true extent of AVM since sometimes you can’t see AVM b/c of blood in the area , so have to have patient come back for re-imaging. options: -surgical treatment -endovascular treatment - embolization -radio surgery (<3 cm) -endovascular treatment + surgery

24
Q

data recommendations for AVM management

A

SBP < 160 or MAP 110 Glucose: 180 normothermia treat clinical or electrographic seizure, but don’t prophylax.

25
Q

where can you have traumatic ICH?

A

frontal, temporal, occipital - anywhere with bony contact.

26
Q

what are ICH complications?

A
  1. hematoma enlargement - over a few hours, re-bleeding. -HTN after hemorrhage -meaningful if 30% increase in 3 hours 2. cerebral edema (increased ICP) -likely happen over couple of days from swelling/irritation from blood on brain -inflammation and vasogenic edema -mass effect (edema volume may be larger than ICH) 3. intraventricular hemorrhage -next few days -occurs with caudate or thalamic hemorrhage -volume of IVH modifies outcome, can get hydrocephalus.
27
Q

what is the CTA spot sign?

A

-should not be confused with the MCA dot sign in the sylvan fissure -it’s a univocal contrast enhancement within the ICH -this area will keep bleeding - predictive of hematoma expansion -suggests the dynamic, active hemorrhage HTN bleeds

28
Q

what would you use to check on the status of AVM 2-3 weeks after initial imaging?

A

diagnostic cerebral angiogram

29
Q

what’s a confirmatory test you can do for subarachnoid bleed?

A

LP - if it’s a bleed you’ll see blood produces in the tap

30
Q

definition of aneurysm

A

localized widening of an artery, wall is weakened and may rupture. it must involve all 3 vascular layers

31
Q

what is a pseudo aneurysm dilation?

A

caused by damage to one or more layers of the artery as a result of arterial trauma

32
Q

where is the most common SAH?

A

anterior communicating artery

33
Q

risk factors for aneurysm development

A

HTN atherosclerotic disease smoking trauma - primarily cause pseudo aneurysm GENETIC -polycystic kidney -ehlers danklos type IV -pseudoxanthoma elasticum -fibromuscular dysplasia -familiam intracranial aneurysm

34
Q

when do aneurysms become symptomatic?

A

local compression subarachnoid hemorrhage unruptured aneurysms rarely cause symptoms unless causing local compression

35
Q

incidence of SAH

A

-incidence increases with age, most commonly between 40-60, high mortality

36
Q

what happens to sensitivity of CT as time passes?

A

it’ becomes less and less sensitivity, at 2 weeks from onset it is only 30% sensitive

37
Q

on what does sensitivity of CT in detecting SAH depend?

A
  1. generation of scanner 2. who is reading the scan 3. amount of blood
38
Q

what should you think about if you’re getting the scan later re: SAH

A

do LP in a timely fashion so you know if there is blood in the area.

39
Q

what are signs of meningeal irritation?

A

Krening’s sign. or you can push on their eyes, if have meningitis, it will give them bad meningeal pain. seen in about 75% of patients and can take several hours to develop

40
Q

what is imaging modality for aneurysm, CT?

A

CT angiogram -uses contrast dye to highlight intra cranial vessels -less sensitive for small aneurysms less than 3 mm -may be done rapidly but care should be used in patients with unknown renal function

41
Q

what is imaging modality for aneurysm, MRA?

A

MR angiogram -does not require contrast -can take a long time to acquire high quality images -degraded by movement -can miss aneurysm < 3 mm -MRA highly sensitive & specific for detection of intracranial aneurysms.

42
Q

conventional angiography?

A

the ‘gold standard’ -20% of small aneurysms can be missed

Acute Care II - Summer 2017 (10 decks)

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