Chapter 6. Guidelines of the Management of Hemorrhagic Stroke Flashcards
Incidence of ICH
24.6/100,000
This is the classification of ICH based on Etiology
SMASH-U Structural lesion Medication Amyloid Systemic Disease Hypertension Undetermined cause
This is secondary to weakened arteriolar walls and formation of microaneurysm
Charcot Bouchard Aneurysm
This is the most important cause of ICH in elderly and non-hypertensive
Cerebral amyloid angiopathy (CAA)
What are clues for CAA
lobar hemorrhage
Multiple
non-hypertensive
Sites of predilection of ICH
Basal ganglia 40-50% Lobar - 20-50% Thalamus - 10-15% Pons 5-15% Cerebellar 5-10%
What blood vessel rupture in putaminal hemorrhage
Ascending lenticulostriate
What blood vessel rupture in thalamic hemorrhage
Thalamogeniculate of PCA
What blood vessel rupture in pontine hemorrhage
paramedian branch of basilar artery
What blood vessel rupture in Cerebellar hemorrhage
penetrating branch of PICA, AICA and SCA
This area when ruptures is considered as neurological emergency
inferior cerebellar hemorrhage
This scoring predict patient with ICH to attain independence at 90 days
FUNC score
When to treat BP of patient with ICH
SBP > 180
What are the treatment for bleeding abnormality secondary to elevated INR to VKA
- Vit K with FFP
2. Prothrombin complex conc alternative to FFP
What are the treatment for bleeding abnormality secondary to NOACs
- Activated cvharcoal
- INR reversal by Platelet concentrate and recombinant FVIIa
- Vit K
The only approved AED prophylactic use
Giant Aneurysm
What is the agent used to reduce cerebral vasospasm
MgSO4
Classification of timing of surgery in SAH
Early: within 72 hours
Late: beyond 3 days
Who are the candidates for early surgery in SAH
- good to moderate grade anuerysm
2. Poor grade aneurysm with hydrocephalus and hematoma
Surgery can be delayed in SAH in the presence of
- ischemia
2. Severe angiographic vasospasm
This is a high flow high pressure vascular lesion that shunts arterial blood to venous system via nidus
Cerebral AVM
Bleeding risk of Cerebral AVM
2-4% per year
Mortality rate of AVM
10%
Presentation of AVM
Hemorrhage 50%
Seizure 25%
This occur due to siphoning of blood flow away from the adjacent brain tissue
Vascular steal syndrome
Candidate for Immediate Surgery in ICH
- Cerebellar hemorrhage > 3 cm who are deteriorating
- ICH secondary to structural lesion (AVM etc)
- Clinically deteriorating patient esp young with moderate to severe lobar hemorrhage
- Ventricular draining for patient with IVH and hydrocephalus
Non-candidate for surgery
- Small hemorrhage
- GCS < 5
- Pontine and midbrain hemorrhage
Sensitivity of SAH based on ictus
12 hours - 98-100%
24 hours - 93%
6 day - 57 - 85%
What is the gold standard diagnostic tool for SAH
DSA
When is the ideal time to repeat a negative DSA result in SAH
7-14 days
What is the equation of ICH lifetime risk in patient with AVM
= 105 - patient age in years
What is the consistent risk factors that may predispose to bleeding in AVM
Deep venous drainage
Single draining vein
Venous stenosis
Elevated MAP in feeding artery
What are the phases of DSA vascular structures
Early arterial (1-2secs) Late arterial (2-3secs) Capillary (3-4secs) Early venous (5-6secs) Late venous (6-7secs)
Abnormalities in Early arterial
AVF - feeding arteries
AVM - feeding arteries
Abnormalities in late arterial
AVF - draining veins and sinuses
AVM - nidus
Abnormalities in capillaries
AVM - Draining vessels and veins
Eloquent areas
Dominant hemisphere Hypothalamus Thalamus Brainstem Cerebral peduncle
This scoring can predict the surgical risk of patient with AVM
Martin Speltzer
AVM score for radiosurgery
(0.1) (volume) + 0.02 (age) + (0.5) (location)
Interpretation of AVM score
<1 - 89%
1.01-1.5 - 70%
1.51 - 2.00 - 64%
> 2.00 - 46%
What is the obliteration rate of SRS in AVM
60-90%
What is the perioperative complication of SRS
28%
What is the reduction rate of gamma knife after 2 years
91%
What is the management of SM I & II
Surgical excision
What is the management for SM IIIa
Microsurgery and embolization
What is the management for SM IIIb
SRS with or without embloization
What is the management for SM IV and V
conservative and palliative
Rate of hemorrhage without bleeding in AVM
1.4%
What is the trial that compared the outcome of medical vs surgical management of AVM
ARUBA tria;
What is the outcome of SM I and II
SM I - 92-100%
SM II - 94-95%
What is the outcome of SM IV and V
SM IV - 71-75
SM V - 50-70%
The success rate of SRS in 2-3 years
60-90%
Hemorrhage rate of SRS
4.8% first 2 years
5% 3-5th year
3 Goals of SRS
- Decrease target size to < 3 cm
- Eradicate angiographic predictor of hemorrhage
- Decrease symptoms related to venous hypertension
What is the recanalization rate of SRS
14-16%