Intracranial Hemorrhage Disorder

Question 1

What are the 2 most common types of intracranial hemorrhage seen in stroke & what demographics are most commonly affected by each?

Answer 1

• Subarachnoid hemorrhage (5-10% all strokes)
  
  • mean age ~50 yr
  • 55% men - but men predominate until 50
• Intracranial hemorrhage (10-15% all strokes)
  
  • after 55 yr
  • men > women

Question 2

Identify the type of hemorrhage indicated by the black blocks show on the provided image:

Answer 2

Question 3

What is the most common cause of a epidural hemorrhage?

Answer 3

traumatic, s/p skull fracture involving middle meningeal artery

Question 4

What is the most common cause of subdural hemorrhage?

Answer 4

usually post traumatic s/p fall in elderly patient causing rupture of bridging veins

Question 5

What is the most common cause of intraparenchymal hemorrhage?

Answer 5

hypertension, tumor

Question 6

What is the most common cause of subarachnoid hemorrhage

Answer 6

trauma, aneurysm rupture

Question 7

What areas are predisposed to having intraparenchymal hemorrhage?

Answer 7

basal ganglia

frontal & posterior(?) lobes

Question 8

What type of hemorrhage is depicted in the provided image?

What is the classic presentation of this type of hemorrhage?

Answer 8

Epidural hematoma

Presentation: head trauma w/ brief loss of consciousness → lucid interval → obtunded state → headache

Question 9

What is the most common location for an epidural hematoma & what findings would you expect to see on an exam?

Treatment?

Answer 9

temporal lobes

contralateral hemiparesis & ipsilateeral pupil dilation

treatment: operating room

Question 10

What type of hemorrhage is depicted in the provided image?

What is the classic presentation of this type of hemorrhage?

Answer 10

Subdural Hematoma

head trauma, headache, alerted awareness

Question 11

What demographics are most commonly affected by subdural hematoma & what findings would you expect to see on an exam?

Treatment?

Answer 11

elderly with atrophy / alcoholism

treatment: situational

Question 12

What does the FUNC score estimate?

Answer 12

the likelihood of functional independence 90 days after diagnosis of intracranial hemorrhage

Question 13

FUNC score is dependent on what variables?

Answer 13

blood volume

age

location of hemorrhage

Glasgow coma scale

pre-ICH cognitive impairment

Question 14

Surgeons hold that operation is warranted for intracerebral hemorrhage if the blood volume is what number?

Answer 14

30 or more

Question 15

0% of patients with a FUNC score of what number gained functional independence after 90 days?

Answer 15

4 or less

Question 16

80% of patients with a FUNC score of what number gained functional independence after 90 days?

Answer 16

11

Question 17

What type of hemorrhage is depicted in the provided image?

Answer 17

Subarachnoid (sulci have a lot of hyperdensities)

also has interventricular extension

Question 18

What type of hemorrhage is depicted in the provided image?

Answer 18

Stroke with hemorrhagic transformation

Question 19

What factors predispose someone to having a hemorrhagic stroke?

Answer 19

• Hypertensive vascuopathy (5x)
• cerebral amyloid angiopathy
• aneurysm / AV malformation
  
  • esp subarachnoid
• excessive EtOH intake
• Smoking (1.5-2x)
• Illicit drugs
  
  • cocaine / amphetamines
• Women with migraine aura

Question 20

What is the most common cause of non-traumatic lobar ICH in the elderly?

Answer 20

cerebral amyloid angiopathy

Question 21

What type of hemorrhage is depicted in the provided image?

What is the classic presentation of this type of hemorrhage?

Answer 21

Intraparenchymal Hemorrhage

progressive headache, lethargy, vomiting & stroke symptoms

Question 22

How do vascular territories help differentiate between ischemic stroke & intraparenchymal hemorrhage?

Answer 22

ischemic: respect of vascular territory

intraparenchymal hemorrhage: no respect of vascular territories

Question 23

What are the symptoms of a primary brain hemorrhage in the following area:

basal ganglia

Answer 23

contralateral hemiparesis

sensory loss

contralateral conjugate gase paresis

Question 24

What are the symptoms of a primary brain hemorrhage in the following area:

lobar regions

Answer 24

contralateral hemiparesis or sensory loss

aphasia

neglect

confusion

Question 25

What are the symptoms of a primary brain hemorrhage in the following area: Thalamus

Answer 25

contralateral hemiparesis sensory loss abnormal eye movement

Question 26

What are the symptoms of a primary brain hemorrhage in the following area: pons

Answer 26

quadriparesis facial weakness decreased level consciousness miosis

Question 27

What are the symptoms of a primary brain hemorrhage in the following area: cerebellum

Answer 27

ataxia gaze paresis herniation coma

Question 28

Subarachnoid hemorrhages are often caused by what?

Answer 28

aneurysm rupture

Question 29

Where do aneurysms commonly occur? Where do aneurysms commonly rupture?

Answer 29

anterior communicating artery (pupillary abnormalities & extraocular movements) Posterior circulating aneurysms have high risk of rupture

Question 30

What is shown in the provided image?

Answer 30

saccular (berry) Aneurysm

Question 31

What is the presentation of a patient with a subarachnoid hemorrhage?

Answer 31

“worst headache ever" with nausea, vomiting, photophobia, neck stiffness, decreased level consciousness, ocular vitreous hemorrhage; (seizure is atypical)

Question 32

What are both the modifiable & non-modifiable risk factors for subarachnoid hemorrhage?

Answer 32

* non-modifiable * age, female, prior history of aneurysmal SAH, family history aneurysm in 1st degree relative, cerebral aneurysm \>7mm * modifiable * hypertension, cigarette smoking, heavy alcohol use, sympathomimetic drug use (cocaine)

Question 33

What are the two type of grading scales for subarachnoid hemorrhage?

Answer 33

* Hunt Hess grade (survival) * take into account clinical status, responsiveness, & degree neurologic deficit * Radiographic (spasm risk) * based on radiographic imaging * important for plan or care

Question 34

If a SAH is suspected, but the CT is negative, what should you do?

Answer 34

* lumbar tap to look for xanthochromia (collected in 4 separate tubes) * seen 12 hr after SAH develops * absent after 14 days * CT angiogram to exclude aneurysm * MRI to evaluate possible vascular malformation

Question 35

CT is 98-100% sensitive for SAH when performed within what timeframe?

Answer 35

12 hrs

Question 36

Eye pointing “down & out” is indicative of what nerve palsy? In what situations is the pupil dilated & in what situations is is spared?

Answer 36

CN III * dilated * PCOM aneurysm vs. tumor * spared * intrinsic nerve ischemia (ie. diabetes)

Question 37

What are the goals of treatments for SAH?

Answer 37

* Prevent-re-bleeding * prevent vasospasm * endovascular coiling * maintain euvolemia * maintain normla intracranial pressure

Question 38

How do we prevent rebedding in patients with SAH? When is the highest risk of this happening?

Answer 38

systolic blood pressure \<160mmHg first 6 hrs

Question 39

How do we prevent vasospasm in patient with SAH? Why do we want to prevent this?

Answer 39

nimodipine in all patients decreases risk of delayed cerebral ischemia (4-14 days after SAH)

Question 40

Why might a person have a poor outcome in the situation of SAH?

Answer 40

* if don't optimize fluid, BP, sodium * non-optimal body temperature * anemic * hypoglycemia

Question 41

What are the principles of critical care management?

Answer 41

* blood oxygen content & delivery * fuel (glucose) content & delivery * oxygen consumption

Question 42

The complication of a hyoptonic hyopnatremic state can occur in what situations?

Answer 42

* SAH (⅓ all patients) * ICH * Massive stroke * severe TBI * meningitis/encephalitis

Question 43

What are the complications we see in patients with SAH?

Answer 43

* cerebral edema * seizures * herniation * neurogenic shock * hypertension * rebleed * reversal anticoagulation agents * no tPA * exception: DVT prophylaxis

Question 44

Why might you get a MRI if you see hyperdensity on CT of the head?

Answer 44

to see the arteriovenous malformations that are present in 0.1-0.2% of population

Question 45

What is arteriovenous malformation & why can it be a problem?

Answer 45

fistulous connections of arteries & veins without normal intervening capillary beds 40% intracerebral hemorrhage in patients 15-45 due to AVM presentation is hemorhhage/seizures

Question 46

What are cavernous malformations & why can they cause a problem?

Answer 46

vascular malformations composed of endothelial-lined caverns; endothelia has defective tight junctions which can leak may co-exist with developmental venous anomaly present with brain hemorrhage / seizures

Question 47

Patients with cavernous malformations are more at risk of rupture with what additional predisposing conditions? How does a cavernous malformation appear on imaging?

Answer 47

if located in brainstem in a female with multiple other CM popcorn/mulberry appearance

Question 48

What is the main cause of developmental venous anomolies?

Answer 48

via intrauterine event resulting in focal arrest of venous development rarely symptomatic

Question 49

What can reduce morbidity & mortality in subarachnoid hemorrhage & intracerebral hemorrhage?

Answer 49

early surgery & critical care management