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Neuro Block 2 > Hemorrhagic Stroke (2) > Flashcards

Hemorrhagic Stroke (2) Flashcards

0
Q

What two types of hemorrhagic strokes exist?

A
  1. Parenchymal or intracerebral

2. Subarachnoid

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1
Q

What percent of all strokes do hemorrhagic strokes represent?

A

20%

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2
Q

What are the four types of cerebral hemorrhage?

A
  1. Subarachnoid hemorrhage
  2. Intracerebral hemorrhage
  3. Epidural hemorrhage
  4. Subdural hemorrhage
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3
Q

What is the MCC of a subarachnoid hemorrhage?

A

Rupture of a saccular (berry) hemorrhage

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4
Q

At what size do saccular (berry) hemorrhages need to be surgically treated due to high risk for bleed?

A

5 mm or greater –>(rupture and bleed at a rate of 1-3% per year)

*less than 2 mm aneurysms rarely bleed

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5
Q

In general, where are berry aneurysms likely to occur? Where specifically is the most common site?

A

At bifurcations in the circle of Willis

  • bifurcation of the anterior communicating artery is most common site; also occur at bifurcation of the posterior communicating fairly commonly
  • *vast majority occur in the anterior circulation
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6
Q

What are 6 risk factors for subarachnoid hemorrhage, other than genetic diseases?

A
  1. Tobacco use
  2. EtOH use
  3. HTN
  4. Oral contraceptives
  5. Stimulant drugs
  6. LOW cholesterol
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7
Q

What are 3 genetic diseases that are risk factors for subarachnoid hemorrhage?

A
  1. Polycystic kidney disease
  2. Marfan’s syndrome
  3. Ehlers-Danlos syndrome
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8
Q

What percent of pts with ruptured aneurysm causing subarachnoid bleed died before getting to ER? What percent die in next 3 months? What percent of those surviving initial bleed will have neurologic sequelae?

A

10-15% die before getting to ER

25% die within 3 months–> so overall mortality ~40%

~40% of those surviving initial bleed have neurological sequelae

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9
Q

What are 4 symptoms of a ruptured berry aneurysm/ subarachnoid hemorrhage?

A
  1. Sudden, severe headache–> “Worst headache of my life”
  2. Rapid loss of consciousness (some, not all pts)
  3. Meningeal signs- neck stiffness, photo/phonophobia
  4. Nausea/ Vomiting
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10
Q

What kind of focal neurological signs are seen with a subarachnoid bleed?

A

They are frequently minimal or absent altogether

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11
Q

What causes the headache and loss of consciousness in subarachnoid bleed?

A

Large pulse pressure change to brainstem as a result of arterial blood entering the subarachnoid space

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12
Q

What causes the neck pain, photophobia and phonophobia? Time frame?

A

Meningeal irritation secondary to the breakdown products of RBCs lying in the CSF (called meningismus)

  • may not occur until a few hours after rupture of aneurysm/bleed; takes the RBCs a bit to get in CSF and then lyse
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13
Q

What other two signs can products of RBC breakdown cause in subarachnoid hemorrhage?

A

Abnormal vital signs–> elevated BP and cardiac arrythmias, due to irritation of brainstem centers regulating heart rate

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14
Q

What sign seen in subarachnoid hemorrhage may be seen with an eye exam?

A

Retinal hemorrhages

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15
Q

Although variably present, what focal neurological deficit may be seen in subarachnoid hemorrhage due to rupture of an aneurysm at the junction b/n internal carotid and posterior communicating artery?

A

CN III paresis–> dilated pupil and opthalmoparesis

16
Q

What focal neurological signs may be present due to ruptured aneurysm in the anterior cerebral artery? (In a subarachnoid hemorrhage)

A

Paraparesis (paresis, esp of lower limb)

17
Q

What focal neurological sign may be present in subarachnoid hemorrhage due to rupture of middle cerebral artery aneurysm?

A

Hemiparesis

18
Q

What difference in presentation may help distinguish strokes due to subarachnoid hemorrhage from an ischemic stroke?

A

The absence of focal neurological signs–> although they may be present at times, they frequently are not; the fact that they may be there is what makes it hard to distinguish based on clinical presentation alone

19
Q

What is the most important diagnostic test to identify a subarachnoid hemorrhage?

A

Non-contrast CT–> helps determine the amount of blood, locTion and the likelihood of a delayed complication=vasospasm

20
Q

What is the only method to 100% rule out a subarachnoid hemorrhage?

A

Lumbar puncture–> should have blood in it; a some CT scans wil be false negative, particularly if the bleed is small or it is a day or two after the rupture

21
Q

What must a lumbar puncture (which MUST be done in cases of suspected subarachnoid hemorrhage along w/ non-contrast CT) be delayed for 3-4 hours after onset of symptoms?

A

Have to give RBCs time to lyse and release Hgb into the CSF–> otherwise, blood seen in the CSF drawn could be from nicking a vein while performing the lumbar puncture

*centrifuge the CSF IMMEDIATELY= this will cause the intact RBCs from any blood due to a nicked vein to be spun down

22
Q

What will centrifuged CSF look like if the blood is actually from an accidental venous nick? What if it’s from an actual subarachnoid bleed?

A

CSF will be clear after centrifuge if from an accidental source; will be red if from a subarachnoid bleed which has had time for RBCs to lyse in the CSF ad and release Hgb

23
Q

What is Kerning’s sign? What does it indicate?

A

Resistance to full extension of the knee when the hip is flexed–> is a sign of meningeal irritation

24
Q

What is the Brudzinski sign? What does it indicate?

A

Flexion of both hips and knees when the head is flexed forward–> also a sign of meningeal irritation

25
Q

What is xanthochromia?

A

Yellow discoloration of CSF due to break down of Hgb–> takes a day or two to develop, so not seen at first in an acute presentation

26
Q

Once a subarachnoid bleed is confirmed via CT/ lumbar puncture, what is the gold standard for identifying the location of the bleed?

A

4-vessel digital subtraction arteriography (should demonstrate one or more aneurysms)

*MRI also works pretty well, esp if the aneurysms are large

27
Q

What is the definitive tx for a berry aneurysm (subarachnoid hemorrhage)?

A

Placement of coils with intra-arterial catheter (causes aneurysm to clot and seal itself)
OR surgical placement of a clip at the neck of the aneurysm (or combo of the two)

28
Q

What are three common causes of parenchymal brain hemorrhage in order of frequency?

A
  1. Head trauma
  2. Hypertension
  3. Arterio-venous malformations
29
Q

What kind of specific microaneurysms does hypertension cause?

A

Charcot Bouchard aneurysms

30
Q

What four places in the brain do hypertensive bleeds most commonly occur? **

A
  1. Basal ganglia (30%)
  2. Thalamus (20%)
  3. Cerebellum (10%)
  4. Pons (5%)

Bleeds in these locations due to HTN, so commonly if not always caused by Charcot Bouchard aneurysms; is b/c these areas have small penetrating arterioles that are dilated in these aneurysms

31
Q

What test is needed to identify an arteriovenous malformation that may be the cause of a parenchymal hemorrhage?

A

CT WITH contrast

W/o contrast, hard to see the malformations, which exist below the arachnoid mater

32
Q

What are 3 goals of treatment for hypertensive/ traumatic parenchymal hemorrhages?

A
  1. Correct any bleeding problems (Give Vit K, fresh frozen plasma, rFVIIa, Prothrombin complex concentrate as needed)
  2. Reduce BP to less than 160/100 or MAP to less than 130 mmHg
  3. Monitor for and treat elevated intracranial pressure
33
Q

Other than neuroSx, what are 2 ways to treat elevated intracranial pressure? Desired range of ICP?

A
  1. Hyperventilate
  2. Diuretics (osmotic)

*maintain CPP between 60-80 mmHg

34
Q

What is tx for arteriovenous malformation?

A

Coils, sx removal, or obliteration with gamma knife x-ray device

Neuro Block 2 (11 decks)

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