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ICH > ICH > Flashcards

ICH Flashcards

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
Q

Intra early rebleeding from ICH

A

3 hr ultra early in 40% and 16 % within 3-6 hr , 14 % wishing 24
Spot sign indicated worse prognosis

26
Q

Late rebleedign ICH

A

DBP > 90 , DM , CAA , tobacco , alcohol 🍺

27
Q

Cause of edema ICH

A

Thrombi ➡️⬆️ BBB ➡️ vasoconstrictor and edema

28
Q

DX ICH

A

CT w/o 🔺 ischemic vs hemorrhagic
CT A identify risk of hematoma expansion ➡️ spot sign
CTV ! MRI!MRA !DSA

29
Q

ellipsoid method

A

AP * LAT x HT ( if only axial thickness * num slides ) /2
> 30 cc worse outcome

30
Q

Size of ICH closet decrease by

A

0.75mm/ d

31
Q

Density of ICH ⬇️ by

A

2 CT unit / day
Little change in 1st 2 week

32
Q

Indication for CTA in ICH

A

SAH
CVT ⬆️ dural sinus attenuation
Enlarged vessels or calcifications ➡️AVM
Lobar ICH
IVH

❌ in age > 45 , HTN + ICH BG , posterior fossa , anticoagulant,

33
Q

MRI signal for ICH

A
34
Q

ICH score the higher toe worse

A
35
Q

❌ not recommended IN ICH TX

A

prophylactic ASMs
Steroids
EVD cerebellar hemorrhage

36
Q

Follow up

A

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
Q

BP in ICH

A

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
Q

coagulopathy in patients with ICH

A

🩸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
Q

Start DVT prophylaxis

A

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
Q

platelet indication for transfusion

A

If PC < 50 k
If ICH better to keep PC > 100 K to 75 K
Start ⭐️ with 6 IU platelets

41
Q

Resume anticoagulant ICH

A

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
Q

Risk of developing Strok after cessation anticoagulant

A

Stop 🛑 warfarin for 10 days ➡️ risk of infarction 2.9%
Prosthetics ❤️ valve 2.6%
Atrial fibrillation 4.8%
Cradiogenic embolization 20%

43
Q

IVC in ICH indication

A

HC
IVH
For monitoring ICP 🎯 CPP 50-70 mmhg
tPA
GCS < 8 with transtentorial herniation or significant IVH or hydrocephalus
❌🚫 cerebella’s ICH

44
Q

Indication for medical TX in ICH

A

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
Q

Surgery indication ICH

A

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
Q

ICH TX

A

Medical if size < 3 cm
If size > 3 cm , HC of compression ➡️🚨 Surgery ASAP

47
Q

tPA IVH

A

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
Q

Outcome

A

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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