ICH & SAH

Question 1

intracranial hemorrhage

Answer 1

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

Question 2

what’s the pacing of a subdural hematoma?

Answer 2

slow

Question 3

what’s the pace of a epidural hematoma?

Answer 3

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

Question 4

what’s the leading cause of ICH?

Answer 4

trauma

Question 5

what are the other causes of non-traumatic ICH

Answer 5

HTN, aneurysm, then AV malformation/other

Question 6

primary causes of ICH?

Answer 6

HTN, cerebral amyloid angiopathy, drugs, coagulopathy

Question 7

secondary causes of ICH

Answer 7

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

Question 8

what are pathological changes of HTN hemorrhage

Answer 8

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

Question 9

where in the brain do HTN bleeds happen

Answer 9

Question 10

how do you manage ICH?

Answer 10

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

Question 11

BP control guidelines

Answer 11

Question 12

how do you achieve hemostasis w/ warfarin

Answer 12

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

Question 13

hemostasis w/ antiplatelets

Answer 13

1. platelet transfusion 2. dDAVP (clotting promoter)

Question 14

hemostasis w/ direct thrombin inhibitors (dabigatran etc)

Answer 14

1. activated prothrombin complex concentrate or 2. recombinant factor VII

Question 15

hemostasis w/ novel oral anti-coagulation

Answer 15

activated prothrombin complex concentrate

Question 16

what is Cushing’s triad

Answer 16

bradycardia, widening pulse pressure, irregular respirations

Question 17

what is Monroe Kellie hypothesis

Answer 17

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

Question 18

what is a cerebral arteriorveous malformation (AVM)

Answer 18

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

Question 19

common presenting symptoms of AVM

Answer 19

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

Question 20

physiology of AVM

Answer 20

at least one fistula between arterial and venous circulation

Question 21

what does AVM look like?

Answer 21

has peppered appearance

Question 22

how do you grade an AVM?

Answer 22

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

Question 23

treatment for AVM

Answer 23

-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

Question 24

data recommendations for AVM management

Answer 24

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

Question 25

where can you have traumatic ICH?

Answer 25

frontal, temporal, occipital - anywhere with bony contact.

Question 26

what are ICH complications?

Answer 26

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.

Question 27

what is the CTA spot sign?

Answer 27

-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

Question 28

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

Answer 28

diagnostic cerebral angiogram

Question 29

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

Answer 29

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

Question 30

definition of aneurysm

Answer 30

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

Question 31

what is a pseudo aneurysm dilation?

Answer 31

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

Question 32

where is the most common SAH?

Answer 32

anterior communicating artery

Question 33

risk factors for aneurysm development

Answer 33

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

Question 34

when do aneurysms become symptomatic?

Answer 34

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

Question 35

incidence of SAH

Answer 35

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

Question 36

what happens to sensitivity of CT as time passes?

Answer 36

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

Question 37

on what does sensitivity of CT in detecting SAH depend?

Answer 37

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

Question 38

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

Answer 38

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

Question 39

what are signs of meningeal irritation?

Answer 39

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

Question 40

what is imaging modality for aneurysm, CT?

Answer 40

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

Question 41

what is imaging modality for aneurysm, MRA?

Answer 41

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.

Question 42

conventional angiography?

Answer 42

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