39 - Treatment of hemorrhagic stroke Flashcards
SAH vs ICH
SAH = SubArachnoid hemorrhage
an EXTRAVATION of blood into the SUBARACHNOID SPACE
- *ICH =** IntraCerebral hemorrhage
- *BLEEDING** into the PARENCHYMA of the brain
- *ICH > SAH**
- *In Cccurance & Mortality**
Causes of
SAH vs ICH
SAH
TRAUMA > Rupture of Aneurism > AV Malformations
Neoplasm > Coagulopathy
UNKNOWN
ICH
SPONT. SMALL VESSEL RUPTURE
> AV malformations > rupture of aneurisms
“
- *Key RISK FACTOR differences**
- *SAH vs ICH**
SAH
FAMILY HISTORY
Men > WomenB450 y/o–>women>men
Age > 50
ICH
Same Modifiable = HTN/Smoking/EtOH/Cocaine
except for: +ANTICOAGULATION
Nonmodifiable: AMYLOID AGIOPATHY
AA / ASIANS > europeans
Key S/Sx of
SAH > ICH
NAUSEA** + **VOMITTING
LOC
Level of Conciousness -> Comatose
Seizures
↑Intracranial Pressure
Key S/Sx of
ICH > SAH
WORST HEADACHE OF MY LIFE
+
Nuchal RIGIDITY** or **NECK PAIN
LOC
Level of Conciousness -> Comatose
Seizures
↑Intracranial Pressure
DIAGNOSIS
of
Hemorrhagic Strokes
CT** = **Computerized Tomography
FAST & FIRST LINE
Lumbar Puncture
mainly to CONIRM
Cerebral Angiogram
used to ID the SOURCE of BLEEDING, invasive
need to caution with RENAL INSUFFICIENCY
Contrast induced nephropathy:
HYDRATE -> sodium bicarb / acetylcysteine
- *aSAH**
- *Surgical Intervention**
EARLY Intervention < 3 days post bleed
Surgical Approach:
CRAINIOTOMY for CLIPPING
Percutaneous Transluminal angiographic placement of:
COILS** or **GLUE
other:
Placement of Extraventricular drain for hydrocephalus
or Central lines** + **arterial lines
- *aSAH**
- *Requirements b4 Surgery** & Agents used?
SBP <160
some recommend < 140mmhg
BP Controling agents:
- *NICARDIPINE** - infusion, PREFERRED
- *NITROPRUSSIDE** - infusion
- *LABETALOL** - infusion or IV push
Sedation:
Propofol / Dexmedetomide
Analgesia:
Morphine / Fentanyl
NIMODIPINE
Nimotop / Nymalize
INDICATION / USE / MoA
only approved indication is:
aSAH
↓NEUROLOGICAL DEFICITS
associated with VASOSPASMS
does NOT decrease incidence
MoA:
blocks CA2+ INFLUX** & **VASODILATES
NIMODIPINE
Nimotop / Nymalize
only for aSAH
DOSE
start within:
24 HOURS of ADMISSION
- *60mg PO/NGT**
- *q4h** for 21 days
- if HypoTensive:*
- *30mg q2h**
Dosage forms:
- *30mg caps** & 60mg/20mL solution
- DO NOT BREAK CAPSULE, if they canNOT swallow - USE NGT TUBE*
aSAH
Additional Therapies
- *Stool Softener**
- *Docusate 100-200mg BID/TID**
- to REDUCE BP*
- *DVT Prophylaxis**
- *Heparun 5k SQ q8-12h**
- prevent DVT/PE in other areas*
- *AntiEmetics_ / _Stress Ulcer Prophylaxis**
- *PPI / H2RA**
- *MAINTAIN EUVOLEMIA**
- FLUIDS, AVOID hypoTonic fluids*
Complications of aSAH
Rebleeding / HydroCephalus
Delayed Cerebral Ischemia
HypoNatremia / Seizures
- *ICH**
- *Blood Pressure Management**
If SBP 150-220 & w/o contraindications:
Acute lowering of SBP = 140
If SBM >220, reasonable to consider:
Aggresive reduction w/ continuous infusion + BP monitoring
CPP = MAP - ICP
Cerebral Perfusion Pressure = Mean Arterial Pressure - Intracranial Pressure
ICH
REVERSAL OF COAGULOPATHY
for
WARFARIN
PHYTONODIONE (Vit K)
AND
KCentra
ONE DOSE, based on WEIGHT + INR
contains SNOT factors + heparin** & **albumin
CONTRAINDICATED IN: DIC** + **HIT
ADR:
Stroke / PE / DVT
Monitor:
INR in 30 min + q6-8hours for 24-48 hours
ICH
REVERSAL OF COAGULOPATHY
for
DABIGATRAN
PRAXBIND
MAB fragment that binds to dabigatran’s binding site
Dose:
2.5gm IV over 5 min x2 doses
Alternatives:
FEIBA** 50units/kg OR **KCENTRA 50units/kg
