Neuro Emergencies: Intracerebral Hemorrhage Flashcards by Andrew Kreutzer

Small Vessel Disease Types
Arteriolosclerosis what is it and where does it affect?

Concentric hyalinized vascular wall thickening favoring the penetrating arterioles of the basal ganglia, thalamus, brainstem, and deep cerebellar nuclei

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Small Vessel Disease Types
Arteriolosclerosis
Risk Factors

HTN
DM
Age

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Small Vessel Disease Types
Cerebral Amyloid Angiopathy (CAA) What is it and where does it affect?

Deposition primarily of the Beta-amyloid peptide in the walls of arterioles and capillaries in the leptomeninges, cerebral cortex, and cerebellar hemispheres

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Small Vessel Disease Types
Cerebral Amyloid Angiopathy (CAA)
Risk Factors

Age
apolipoprotein E genotypes containing the ε2 or ε4 alleles

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Mechanisms of ICH - Related Brain Injury
Direct pressure effects what?

Local compression of immediately surrounding brain parenchyma
Perilesional edema
Increase ICP
Hydrocephalus
Herniation
Hematoma Expansion

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Mechanisms of ICH - Related Brain Injury
Secondary physiological and cellular pathways

Biochemical toxicity of blood products such as hgb, iron and thrombin (exact mechanism is unknown)
Cerebral edema
Inflammation

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Typical Hypertensive ICH Locations
50% occur where?
35% occur where?
10% occur where?
6% occur where?

deep
lobar
cerebellar
brainstem

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ICH risk factors include?

Anticoagulation
Bleeding d/o
Older age
Cerebral amyloid angiopathy (CAA)
AVM/Aneurysm/dural arteriovenous malformations/cavernous
Cerebral venous thrombosis
Tobaccos use
Renal or liver failure
Recent CEA
Cerebral neoplasm

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ICH vascular risk factors include?

Ischemic stroke
Prior ICH
HTN
DM
Metabolic Syndrome
HLD
Imaging biomarkers

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Clinical Manifestations of ICH include?

HA common but not always present
N/V
Onset of sudden focal deficit w/ or w/o progression
AMS
ECG changes

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Clinical Evaluation of ICH includes?

ABCs
Neuro assessment
Physical Exam
Onset/Last known normal
Focused Hx

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Clinical Evaluation of ICH
Focused Hx includes?

PMH
Medications
Cognitive impairment or dementia
Social hx (substance abuse)
Liver disease, uremia, malignancy and hematologic d/o

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Clinical Evaluation of ICH
Labs to order include?

CBC
PT/INT & aPTT
CMP
blood glucose
troponin
ECG
Tox screen
ESR
CRP
pregnancy test

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Clinical Evaluation of ICH
Specific test for DOACs?

dilute thrombin time
anti-Xa activity

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Clinical Evaluation of ICH
Imaging?

Head CT or MRI
CTA w/n first few hrs may be reasonable to identify pts at risk for hematoma expansion

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CTA plus consideration of CTV or MRI w/ MRA is recommended in which patient populations?

Pts w/ lobar spontaneous ICH and age < 70
Pt w/ deep/posterior fossa spontaneous ICH and age < 45
Pts w/ deep posterior fossa age 45-70 w/o history of HTN and signs of small vessel disease

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CTA plus consideration of CTV or MRI w/ MRA is used to evaluate for what?

macrovascular cause including:
AVM
aneurysm
dural arteriovenous fistula
cavernoma
cerebral venous thrombosis

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Clinical Evaluation
Digital Subtraction Angiography should be used in patient w/?

spont. IVH and no detectable parenchymal hemorrhage
spont. ICH and a CTA or MRA suggestive of macrovascular causes

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Clinical Evaluation
Initial scans should measure what?

Initial ICH volume

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ICH Volume
How to Calculate
AxBxC/2
A=?
B=?
C=?

A= greatest hemorrhage diameter in the axial plane
B= hemorrhage diameter at 90* to A in the axial plane
C= the number of CT slices with the hemorrhage multiplied by slice thickness
Divide by 2

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How to Calculate an ICH score?

Add points from:
GCS score at presentation
ICH volume
IVH
Origin of ICH
Age

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ICH Score
GCS score at presentation
13-15 =?
5-12 =?
3-4 =?

0
1
2

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ICH Score
ICH volume (cm3)
>/=30 =?
<30 =?

Study These Flashcards

1
0

ICH Score
IVH
Yes =?
No =?

Study These Flashcards

1
0

ICH Score Origin of ICH Infratentorial =? Supratentorial =?

1 0

ICH Score Age >/= 80 =? <80 =?

1 0

ICH Management Acute Blood Pressure lowering Careful titration should be used to ensure what? Should avoid what? Initiate treatment wi/n what timeframe? reaching target w/n how long?

continuous smooth and sustained control of BP Avoid peaks and large variability in SBP 2hrs of onset of ICH; 1hr

ICH Management Acute Blood Pressure lowering For ICH patient presenting w/ SBP between 150 and 220 mmHg acute lower of SBP to a target of what is safe?

140 mmHg w/ a goal of maintaining SBP 130-150 mmHg

ICH Management Acute Blood Pressure lowering In patients w/ mild to moderate ICH presenting w/ SBP > 150 mmHg, acute lowering to what SBP is potentially harmful?

< 130 mmHg

Management of Anticoagulation Reversal Warfarin For patients requiring large volume resuscitation consider what? Reversal agent and dose? reversal based on INR?

FFP 15-20mL/kg Vitamin K 10mg IVPB 4 factor PCC based on INR

Management of Anticoagulation Reversal Warfarin 4-factor PCC based on INR, dosage for: INR 2-3.9 INR 4-6 INR >6

25 u/kg (max 2500u) 35 u/kg (max 3500u) 50 u/kg (max 5000u)

Management of Anticoagulation Reversal DOACs Factor Xa inhibitors get reversed w/?

PCC 50 u/kg (max 5000u) Andexant alpha

Management of Anticoagulation Reversal DOACs Direct thrombin inhibitors get reversed w/?

Activated charcoal 50g (if last dose w/n 2hrs) Idarucizumab 5g IVP

Management of Anticoagulation Reversal Heparin or LMWH get reversed w/?

Protamine 1mg for each 100 u of heparin admin in the last 2 hr (max dose 50mg) Protamin 1 mg for each 1 mg of Enoxaparin (max 50mg)

Management of Anticoagulation Reversal Factor VIIa provides a reduction in? Clinical outcome differences? Risk of?

hematoma expansion no difference thromboembolic events

Management of Anticoagulation Reversal Dabigatran Taken w/n 2 hrs? Is Idarucizumab available: Yes? No?

Activated charcoal 50 g Yes - give 5g IVP No - PCCs or aPCC and or renal replacement therapy

Management of Anticoagulation Reversal Factor Xa - inhibitors Taken w/n 2 hrs? Is andexanet alfa available: Yes? No?

Activated charcoal 50 g Yes - give it No - 4 Factor PCC or aPCC

Anitplatelet-Related Hemorrhage Pt w/ spont. ICH being treated w/ ASA who require emergency surgery, what might be considered?

platelet transfusion

Anitplatelet-Related Hemorrhage Pt w/ spont. ICH being treated w/ ASA not scheduled for emergent neurosurgery platelet transfusions are what?

potentially harmful and should not be administered

General Inpatient Management Prompt transfer to ICU/SDU should be initiated for what?

Neuro assessments Intubation if indicated Analgesia if indicated Cardiac monitoring SMART consult NSGY consult

General Inpatient Management Treatment of elevated ICP includes

Simple measures Aggressive measures 1. Hyperosmolar therapy 2. EVD placement (hydrocephalus, thrombolytic) 3. Hematoma Evac

Surgical treatment Which patient should undergo surgical removal of cerebellar hemorrhages?

Cerebellar hemorrhages w/ neurologic deterioration brainstem compression and/or hydrocephalus from ventricular obstruction have cerebellar ICP > 15mL

Surgical treatment Supratentorial hematoma evac in deteriorating pts might be considered as a life-saving measure when ICH volume =? or GCS is what?

> 20-30 mL 5-12

Surgical Treatment DC w/ or w/o hematoma evac might reduce mortality for patient w/ what?

supratentorial ICH who are in a coma have large hematomas w/ significant midline shift have elevated ICP refractory to medical management

General Inpatient Management Glucose Control Goals

Treat hypoglycemia (<40-60 mg/dL) Maintain BG < 180 mg/dL

General Inpatient Management Fever control should target a temp > what?

37.5*C

General Inpatient Management When should steroids be used?

NO STEROIDS

General Inpatient Management When to give Anti-Seizure Medications?

Treat clinical and electrographic seizures No prophylactic AEDs

General Inpatient Management Prior to discharge BP should be lowered to what? and why?

130/80 mmHg to prevent hemorrhage recurrence

General Inpatient Management When should rehabilitation start?

Early (24-48 hrs after onset)

General Inpatient Management Screenings to consider?

Dysphagia Depression/Anxiety Cognitive

General Inpatient Management DVT prophylaxis should include?

SCDs No graduated compression stockings UFH or LMWH 24-48 hrs from onset IVC for DVT

General Inpatient Management Consider long term antithrombotic therapy in patients with? What to consider? May be safe when?

A-fib/DVT/Mechanical valve/LVAD Risk vs Benefit 2-8 wks after ICH

General Inpatient Management Avoid regular long-term use of what?

NSAIDs

General Inpatient Management In pts w/ spont. ICH and an established indication for statin pharmacotherapy, the risk and benefits of statin therapy on ICH outcomes and recurrence relative to overall prevention of cardiovascular events are what?

uncertain

Neuro Emergencies: Intracerebral Hemorrhage Flashcards

(55 cards)