Ch84 ICH Flashcards
(24 cards)
What % of strokes are due to ICH?
15-30%. Has a slower onset than an ischaemic stroke,
What are the risk factors for ICH?
Old age, Black>white, Male>female, ETOH, Smoking, Drugs, Hypertension and liver dysfunction / coagulopathy.
What are common sites for hypertensive bleeds?
Basal ganglia, pons and cerebellum
What are the causes of lobar haemorrhages?
Cerebral amyloid angiopathy
AVM
Tumour
What is the most common cause of an internal capsule haemorrhage?
Hypertension (Charcot-Bouchard microaneurysms <300 microns of the lenticulostriate perforators) AVM Cavernoma Amyloid angiopathy Anticoagulation / bleeding disorders Drug use
What is cerebral amyloid angiopathy?
Deposition of beta-amyloid (apple green birefringent when stained with congo red and viewed with polarise light).
Associated with apolipoprotein E4 and more prevalent with Down’s
Vessels show fibrinoid necrosis of the wall.
Suspect in patients with recurrent lobar haemorrhages.
What % of patients have amyloid angiopathy?
50% at >70 years
Which mets bleed?
Renal cell ca
Melanoma
Choriocarcioma
(10% of Lung ca)
What is the ICH score?
GCS / Age>80 / Infratentorial / ICH volume >30cc > IVH
Higher the score the greater the 30-day mortality
What are the blood pressure targets following ICH?
Systolic 140
What is the evidence for recombinant factor 7 with ICH?
Not useful
What are the findings of the STICH trial?
Enrolled 1000 patients. Early surgery was median 30 hours. Significant cross over from medial group. No benefit of ICH evacuation but subgroup analysis suggests some benefit it clot size 10-30 cc and within 1 cm of cortex.
Where is a Frazier EVD placed?
3cm lateral and 6 cm above the inion.
How do you treat a cerebellar ICH?
If GCS <13 or haemiatoma >4cm then surgical evaculation.
EVD placement not recommeded due to risk of upward herniation
What are the most common causes for ICH in the young?
AVM > HTN > aneurysms.
Also consider drugs
What is the cause for prematurity IVH?
Germinal matrix haemorrhage as this has a large volume of CBF in prematurity and immature capillaries lack autoregulation and are friable.
Higher risk with pulmonary insufficiency due to raised pCO2.
25% of babies born <1.5 kg will have an IVH
How can prem IVH be prevented?
Antenatal steroids (reduced ARDS)
Indomethacin
Antenatal vitamin K
Delayed cord clamping
What grading system is used for prem IVH?
Papille - 1 = Geminal matrix 2 = IVH no dilation 3 = IVH with dilation 4 = IVH with parenchymal extension
What % of prem IVH results in hydrocephalus?
50% (more likely with grade 3 /4). Aqueduct gliosis is found at autopsy.
What clinical features are suggestive of hydrocephalus following prem IVH?
Increased head circ (crossing centiles) - Based on Levene's 97th centile +4 mm line (1981) Enlarging vents on crUSS Tense fontanelle Seizures Bradycardia Vomiting
How do you manage prem IVH?
Temporising methods until weight >2kg
= LP / fontanelle tap / VAD / VSG
When >2kg then can shunt
What are the risks shunting neonates <2kg?
Necrotising enterocolitis
Infection
Shunt block
Thin skin for tunnelling - may erode
What volume tap / LP should be performed for premIVH?
10ml/Kg
What protein level is recommended for shunting?
<100mg/dl
