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1
Q

2nd common form of the Strok

A
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2
Q

Infarction vs ICH ( hemorrhagic )

A

Ischemic deficit max at onset
ICH smooth progressive and ⬆️ BP ( within 3 hr )

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3
Q

⬆️ morbidity and mortality

A

⬆️ volume hematoma
Anticoagulant
⬆️ troponin
⬆️ RBS
Spot sign on CT

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4
Q

When enlargement happen

A

Early first 3 hr

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5
Q

Target BP

A

If > 150 mmhg reduce to 140

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6
Q

Surgery ICH supratentorial

A

⬇️ ICU stay and mortality ( GCS 7-10 within < 8 hr from the bleeding) , edema , rebleeding

STICH 2 > benefits 1cm from the cortex
Indication ➡️ patients in coma, or
large ICH with significant midline shift,
or elevated ICP refractory to medical management: decompressive craniectomy (DC) with or without ICH evacuation may reduce mortality

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7
Q

Infra tentorium

A

Neurological deterioration or compression brainsteam , obstructive hydrocephalus
🚫 EVD CI

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8
Q

RF ICH

A

Age. > 55
Men
Previous Strok
Alcohol 🍷 moderate within 24 hr or chronic 3*/d ➡️➡️ lobar ICH
Smoking 🚫 ⬆️ risk ICH but ⬆️ SAH , Strok
Drug use
Liver dysfunction

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9
Q

Location Of ICH

A

MCC feeder ::
1-lenticulostriates: the source of putaminal hemorrhages M1
2- thalamoperforators
3-paramedian branches of BA
4-IVH ➡️ worse outcome

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10
Q

Lobar ICH

A

Associated structural abnormalities
More common alcohol 🍺
More benign than BG -ICH
Causes
- extension of deep hemorrhage
- CAA
- Truma
-Hemorrhageic transformation
- hemorrhagic tumors
- CM , AVM
- anurysum
Idopathic

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11
Q

MCC cause of ICH in elderly

A

CAA

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12
Q

Causes of ICH 13

A

1 - HTN
2- acute ⬆️ CBF ; endarterectomy,repaire CHF , Strok ( within 1st month ) ,migarian , NPPB after SVM , extension .
3 - vascular a anomalies; AVM , anurysum ➡️ fibrosis on prevouse bleeding 🩸 ➡️ ICH > SAH
Venous angioma
4- arteriopathies; CAA , fibrioniod necrosis , lipohyalinosis, arteritis
5- brain tumors
6- coagulation or clotting disorde➡️ leukemia, TTP , anticoagulant post tPA ( within 36 hr and high dose > 100 mg ) , ASA ( 🚫⬆️risk in age > 60 )p with GCS 9 )
7- Infection fungal MCC , granuloma , HSV
8- venous sinus thrombosis
9- drugs related ; alcohol , drugs abuse , or alph adenrgic > epinephrine
10- postrumatic
11- pregnancy 🤰🏼 postpartum e 6 wks , postpartum ICH range 8 ds- 1 month
12- post op endarterectomy, craniotomy , NPPB post AVM
13 idopathic

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13
Q

Hemorrhagic transformation

A

Type 1 diffuse or multi focal within the boundaries of Strok , less hyper dens on VT

Type 2 extensive , univocal ,hyper dense outside the Strok boundaries associated with anticoagulant, happened within few days after Strok ➡️ worse prognosis

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14
Q

Cerebellar hemorrhage MCC

A

2/3 of ICH is HTN

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15
Q

Microaneurysms of Charcot-Bouchard AKA miliary aneurysm

A

cur primarily at bifurcation of small (< 300 mcm) perforating branches of lateral lenticulostriate arteries in BG ➡️ BG bleed 🩸

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16
Q

CAA Cerebral) amyloid angiopathy

A

beta amyloid protein accumulation in ➡️ birefringent “apple -🍏 green stain
Recurrent ICH lobar
DX ➡️➡️ MRI GRE , SWI hemosidrien and micro bleed 🩸
Common after 70s

apolipoprotein E ε4 allele assoscated CAA and Alzheimer’s disease
Definitely dx by biopsy
Dx by Boston criteria ;

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17
Q

Malignant tumors cause ICH 3

A

GBM
, lymphoma
METS ( choriocarcinoma➡️ melanoma➡️RCC ➡️ BLCA )

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18
Q

Benign tumor cause ICH 6

A

Meningioma

hemangioblastoma

oligodendroglioma

PitNET/adenoma

vestibular schwannoma

  1. cerebellar astrocytoma
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19
Q

Risk of hemorrhage after anticoagulant

A

cumulative risk of a fatal hemorrhage was 1% at 1 year and 2% at 3 yrs.

Risk of ICH ⬆️ increase prolonged use and PT in the 1 st 3 months

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20
Q

Lobar ICH sx and syndrom

A

TIA + Jacksonian-march seizure
Frontal ➡️ CI hemiparesis arm > legs > face

parietal lobe ➡️ CI hemisensory deficit and mild hemiparesis

occipital➡️ 👁️ pain and CI homonymous hemianopsia
Temporal ➡️ of D ➡️ fluent dysphasia poor auditory comprehension but relatively good repetition

21
Q

Sx of Putaminal ICH

A

(60% gradual vs 30 max at onset
CI hemiparesis, ➡️ hemiplagic and coma

22
Q

Thalamic ICh sx

A

CI hemisensory loss.
If IC ➡️ hemiparesis
If Upper brainsteam➡️ 👀 vertical gaze palsy, retraction nystagmus, skew deviation, loss of convergence, ptosis, miosis, anisocoria, ± unreactive pupils
Hematoma > 3 cm increase mortality

23
Q

Cerebellar hemorrhage

A

⬆️ ICP sx ; HC due to compression 4 V extension of ICH to IVH
Compression brain steam ➡️ facial colliculs ➡️ facial palsy 😜
Coma

24
Q

Delayed deterioration in ICH

A

Rebleeding
Edema
HC ⬆️ w IVH and posteriors fossa ICH
Seizure
High ICP

25
Intra early rebleeding from ICH
3 hr ultra early in 40% and 16 % within 3-6 hr , 14 % wishing 24 Spot sign indicated worse prognosis
26
Late rebleedign ICH
DBP > 90 , DM , CAA , tobacco , alcohol 🍺
27
Cause of edema ICH
Thrombi ➡️⬆️ BBB ➡️ vasoconstrictor and edema
28
DX ICH
CT w/o 🔺 ischemic vs hemorrhagic CT A identify risk of hematoma expansion ➡️ spot sign CTV ! MRI!MRA !DSA
29
ellipsoid method
AP * LAT x HT ( if only axial thickness * num slides ) /2 > 30 cc worse outcome
30
Size of ICH closet decrease by
0.75mm/ d
31
Density of ICH ⬇️ by
2 CT unit / day Little change in 1st 2 week
32
Indication for CTA in ICH
SAH CVT ⬆️ dural sinus attenuation Enlarged vessels or calcifications ➡️AVM Lobar ICH IVH ❌ in age > 45 , HTN + ICH BG , posterior fossa , anticoagulant,
33
MRI signal for ICH
34
ICH score the higher toe worse
35
❌ not recommended IN ICH TX
prophylactic ASMs Steroids EVD cerebellar hemorrhage
36
Follow up
If initially angio -ve reapeat after CT showed reabsorbtion ( 2-3 m ) If still -ve f/u CT or MRI q 4-6 m over 1 y to R/ O tumors
37
BP in ICH
SBP > 150-200 no CI for acute TX lower 🎯 SBP 140 SBP < 140 bad outcome If SBP > 200 mmhg IV infusion ✳️ INTERACT-II 116& ATACH-2 117trials have shown that rebleeding occurs despite blood pressure control,
38
coagulopathy in patients with ICH
🩸If VKA warfarin w/ ⬆️ INR ➡️ hold VKA , K factors replacement , correct INT by PC > FFP PCC less complication correct INT faster and closer to the normal 🩸 dabigatran (Pradaxa®)a, rivaroxaban (Xarelto®)a, or apixaban➡️➡️⬇️ PCC, facto 8 , HD 🩸 heparin ➡️ protamine sulfate 🩸 ASA platelet transduction undertone benift
39
Start DVT prophylaxis
pneumatic compression After cessation of bleeding 🩸 start sub-q heparin’s LMW after 1-4 days from ICH I’d DVT or PE 🚨➡️➡️ systemic anticoagulant or IVC depend IVH stability’s and cause
40
platelet indication for transfusion
If PC < 50 k If ICH better to keep PC > 100 K to 75 K Start ⭐️ with 6 IU platelets
41
Resume anticoagulant ICH
1- nonvalvular a-fib: long-term anticoagulation with warfarin should probably be avoided after warfarin ICH induce 2- for strong 💪 indication consider anticoagulant for non lobar ICH or ASA after sICH timings ⏱️;; OAC after 1 month in patient w/ o mechanical valve after OAC - ICH Mechanical valve ❤️ 1-2wk off Patient CKD ➡️ HD heparine free dialysis’s ASA within days after ICH
42
Risk of developing Strok after cessation anticoagulant
Stop 🛑 warfarin for 10 days ➡️ risk of infarction 2.9% Prosthetics ❤️ valve 2.6% Atrial fibrillation 4.8% Cradiogenic embolization 20%
43
IVC in ICH indication
HC IVH For monitoring ICP 🎯 CPP 50-70 mmhg tPA GCS < 8 with transtentorial herniation or significant IVH or hydrocephalus ❌🚫 cerebella’s ICH
44
Indication for medical TX in ICH
GCS > 10 w/ subtle hemiparesis 😭 High ICH score massive hemorrhaging Dominant LEFT Poor neurological condition GCS 5 , loss of brain steam reflex , fixed diapered pupils 👀 Coagulaoprhys BG ICH ICH volume < 10 or > 30 If volume > 60 ➡️ mortality 90% , diameter 5 cm ➡️ high mortality
45
Surgery indication ICH
ML shift Lesion cause sx ➡️ high ICP Moderate volume 10- 30 cc ⬆️ ICP refractory to medical TX Rapid deterioration foavorable 📍 ; Lobar < 1 cm cortex ,cerebella’s, external capsule , non dominant right Young patient < 50 Within 24 hr from from sx or deterioration
46
ICH TX
Medical if size < 3 cm If size > 3 cm , HC of compression ➡️🚨 Surgery ASAP
47
tPA IVH
Aim lyse clot and IVC patancy Dose 2-5 mg in NS q8 hr for 4 days close EVD for 2 hr CLEAR III trial 1➡️➡️ showed no benefit of using 1 mg tPA vs. saline for the primary endpoint of mRS score ≤ 3 at 6 mos for patients with < 30 ml clot (lower mortality at 6 mos was offset by a larger number of survivors with mRS = 5).
48
Outcome
Lobar > thalamic Dexa 1st week with GCS < 7 ➡️ ⬇️ death but ⬆️ inpatient above > 65 Overall, the 30-day mortality rate is ≈ 44% for ICH, 2which is similar to that for SAH (≈ 46%)

ICH (2 decks)

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