Chapter 6. Guidelines of the Management of Hemorrhagic Stroke

Question 1

Incidence of ICH

Answer 1

24.6/100,000

Question 2

This is the classification of ICH based on Etiology

Answer 2

SMASH-U
Structural lesion
Medication
Amyloid
Systemic Disease
Hypertension
Undetermined cause

Question 3

This is secondary to weakened arteriolar walls and formation of microaneurysm

Answer 3

Charcot Bouchard Aneurysm

Question 4

This is the most important cause of ICH in elderly and non-hypertensive

Answer 4

Cerebral amyloid angiopathy (CAA)

Question 5

What are clues for CAA

Answer 5

lobar hemorrhage
Multiple
non-hypertensive

Question 6

Sites of predilection of ICH

Answer 6

Basal ganglia 40-50%
Lobar - 20-50%
Thalamus - 10-15%
Pons 5-15%
Cerebellar 5-10%

Question 7

What blood vessel rupture in putaminal hemorrhage

Answer 7

Ascending lenticulostriate

Question 8

What blood vessel rupture in thalamic hemorrhage

Answer 8

Thalamogeniculate of PCA

Question 9

What blood vessel rupture in pontine hemorrhage

Answer 9

paramedian branch of basilar artery

Question 10

What blood vessel rupture in Cerebellar hemorrhage

Answer 10

penetrating branch of PICA, AICA and SCA

Question 11

This area when ruptures is considered as neurological emergency

Answer 11

inferior cerebellar hemorrhage

Question 12

This scoring predict patient with ICH to attain independence at 90 days

Answer 12

FUNC score

Question 13

When to treat BP of patient with ICH

Answer 13

SBP > 180

Question 14

What are the treatment for bleeding abnormality secondary to elevated INR to VKA

Answer 14

1. Vit K with FFP

2. Prothrombin complex conc alternative to FFP

Question 15

What are the treatment for bleeding abnormality secondary to NOACs

Answer 15

1. Activated cvharcoal
2. INR reversal by Platelet concentrate and recombinant FVIIa
3. Vit K

Question 16

The only approved AED prophylactic use

Answer 16

Giant Aneurysm

Question 17

What is the agent used to reduce cerebral vasospasm

Answer 17

MgSO4

Question 18

Classification of timing of surgery in SAH

Answer 18

Early: within 72 hours
Late: beyond 3 days

Question 19

Who are the candidates for early surgery in SAH

Answer 19

1. good to moderate grade anuerysm

2. Poor grade aneurysm with hydrocephalus and hematoma

Question 20

Surgery can be delayed in SAH in the presence of

Answer 20

1. ischemia

2. Severe angiographic vasospasm

Question 21

This is a high flow high pressure vascular lesion that shunts arterial blood to venous system via nidus

Answer 21

Cerebral AVM

Question 22

Bleeding risk of Cerebral AVM

Answer 22

2-4% per year

Question 23

Mortality rate of AVM

Answer 23

10%

Question 24

Presentation of AVM

Answer 24

Hemorrhage 50%

Seizure 25%

Question 25

This occur due to siphoning of blood flow away from the adjacent brain tissue

Answer 25

Vascular steal syndrome

Question 26

Candidate for Immediate Surgery in ICH

Answer 26

1. Cerebellar hemorrhage > 3 cm who are deteriorating 2. ICH secondary to structural lesion (AVM etc) 3. Clinically deteriorating patient esp young with moderate to severe lobar hemorrhage 4. Ventricular draining for patient with IVH and hydrocephalus

Question 27

Non-candidate for surgery

Answer 27

1. Small hemorrhage 2. GCS < 5 3. Pontine and midbrain hemorrhage

Question 28

Sensitivity of SAH based on ictus

Answer 28

12 hours - 98-100% 24 hours - 93% 6 day - 57 - 85%

Question 29

What is the gold standard diagnostic tool for SAH

Answer 29

DSA

Question 30

When is the ideal time to repeat a negative DSA result in SAH

Answer 30

7-14 days

Question 31

What is the equation of ICH lifetime risk in patient with AVM

Answer 31

= 105 - patient age in years

Question 32

What is the consistent risk factors that may predispose to bleeding in AVM

Answer 32

Deep venous drainage Single draining vein Venous stenosis Elevated MAP in feeding artery

Question 33

What are the phases of DSA vascular structures

Answer 33

``` Early arterial (1-2secs) Late arterial (2-3secs) Capillary (3-4secs) Early venous (5-6secs) Late venous (6-7secs) ```

Question 34

Abnormalities in Early arterial

Answer 34

AVF - feeding arteries | AVM - feeding arteries

Question 35

Abnormalities in late arterial

Answer 35

AVF - draining veins and sinuses | AVM - nidus

Question 36

Abnormalities in capillaries

Answer 36

AVM - Draining vessels and veins

Question 37

Eloquent areas

Answer 37

``` Dominant hemisphere Hypothalamus Thalamus Brainstem Cerebral peduncle ```

Question 38

This scoring can predict the surgical risk of patient with AVM

Answer 38

Martin Speltzer

Question 39

AVM score for radiosurgery

Answer 39

(0.1) (volume) + 0.02 (age) + (0.5) (location)

Question 40

Interpretation of AVM score

Answer 40

<1 - 89% 1.01-1.5 - 70% 1.51 - 2.00 - 64% > 2.00 - 46%

Question 41

What is the obliteration rate of SRS in AVM

Answer 41

60-90%

Question 42

What is the perioperative complication of SRS

Answer 42

28%

Question 43

What is the reduction rate of gamma knife after 2 years

Answer 43

91%

Question 44

What is the management of SM I & II

Answer 44

Surgical excision

Question 45

What is the management for SM IIIa

Answer 45

Microsurgery and embolization

Question 46

What is the management for SM IIIb

Answer 46

SRS with or without embloization

Question 47

What is the management for SM IV and V

Answer 47

conservative and palliative

Question 48

Rate of hemorrhage without bleeding in AVM

Answer 48

1.4%

Question 49

What is the trial that compared the outcome of medical vs surgical management of AVM

Answer 49

ARUBA tria;

Question 50

What is the outcome of SM I and II

Answer 50

SM I - 92-100% | SM II - 94-95%

Question 51

What is the outcome of SM IV and V

Answer 51

SM IV - 71-75 | SM V - 50-70%

Question 52

The success rate of SRS in 2-3 years

Answer 52

60-90%

Question 53

Hemorrhage rate of SRS

Answer 53

4.8% first 2 years | 5% 3-5th year

Question 54

3 Goals of SRS

Answer 54

1. Decrease target size to < 3 cm 2. Eradicate angiographic predictor of hemorrhage 3. Decrease symptoms related to venous hypertension

Question 55

What is the recanalization rate of SRS

Answer 55

14-16%