Intracerebral haemorrhage Flashcards
What is the typical presentation of an intracerebral haemorrhage?
sudden onset of severe neurological deficit with headache
Generally speaking, what causes haemorrhagic stroke and the clinical deficit that results?
- weakening of cerebral vessels leading to cerebral vessel rupture and haematoma formation
- clinical deficit directly caused by neuronal injury, and indirectly by cerebral oedema
At what point following symptom onset does cerebral oedema reach a peak?
5 days
What proportion of haemorrhagic strokes are intracerebral haemorrhage?
75%
What are 9 strong risk factors that increase the rate of intracerebral haemorrhage?
- Increased age
- Male
- Higher rate in Asian ethnic groups
- Family history of haemorrhagic stroke
- Haemophilia
- Cerebral amyloid angiopathy/hypertension
- Anticoagulation therapy
- Illicit sympathomimetic drugs (cocaine and amphetamines)
- Vascular malformations (particularly younger patients)
What are 3 weaker risk factors for haemorrhagic stroke?
- NSAIDs
- Heavy alcohol use
- Thrombocytopenia
What are 3 important aspects of the acute management of haemorrhagic stroke?
- Neurosurgical and neurocritical care evaluation
- Admission to neuro ICU or stroke unit - may require intubation and ventilation or invasive monitoring of ICPs
- Aim to keep blood pressure <140/80
Why is a neurosurgical and neurocritical care evaluation necessary in the acute management of haemorrhagic stroke?
potential surgical intervention required e.g. decompressive hemicraniectomy
Why should a patient with haemorrhagic stroke be admitted to the neuro ICU or stroke unit?
may require intubation and ventilation or invasive monitoring of ICPs
What is the aim for blood pressure following haemorrhagic stroke?
<140/80
Why is important to keep blood pressure low following a haemorrhagic stroke?
poor BP control in acute stage is associated with poorer outcomes later on
What type of imaging is the gold standard means of detecting intracranial haemorrhage in acute stroke?
Non-contrast CT
How will blood appear following intracerebral haemorrhage on non-contrast CT?
blood is hyerdense initially (white), then as broken down, density declines by 1.5 Hounsfield units per day - becomes hypodense
What is the most common aetiology of basal ganglia haemorrhage?
small vessel disease
What is the most common cause of lobar haematoma?
amyloid angiopathy in the elderly, underlying pathology e.g. AVMs in younger patients
What can cause pontine or supratentorial lobar bleeds?
cavernomas
What medication must you check for in patients with haemorrhagic stroke and what must be done about it?
anticoagulation: return clotting to normal if taking warfarin by using combination of prothrombin complex concentrate and IV vitamin K
What are 2 criteria for patients with acute intracerebral haemorrhage to start rapid blood pressure lowering?
- Present within 6 hours of symptom onset AND
- Have systolic BP between 150-220 mmHg
What is the target systolic blood pressure within 1 hour of starting rapid blood pressure lowering? How long should this be maintained?
130-140 mmHg
maintain for at least 7 days
What are 2 situations when you can consider rapid blood pressure lowering following intracerebral haemorrhage?
- If they present beyond 6 hours of symptom onset OR
- Have systolic blood pressure greater than 220 mmHg
What are 4 contraindications to offering rapid blood pressure lowering following intracerebral haemorrhage?
- Underlying structural cause e.g. tumour, AVM, aneurysm
- GCS below 6
- Going to have early neurosurgery to evacuate the haematoma
- Have a massive haematoma with poor expected prognosis
What are 4 aspects of the management of acute intracerebral haemorrhage regarding surgery?
- Stroke services should agree protocols for monitoring, referring and transferring people to regional neurosurgical centres for management of symptomatic hydrocephalus
- People with ICH should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary
- _Previously fi_t people should be considered for surgical intervention following primary ICH if they have hydrocephalus
- People with certain types of haemorrhage rarely require surgical intervention so should receive medical treatment initially
What is the key thing that would make someone be considered for neurosurgical intervention following ICH?
develops hydrocephalus (and if pereviously fit), or neurological status of patient deteriorates
What are 5 types of ICH that rarely require surgical intervention and should receive medical treatment initially?
- Small deep haemorrhages
- Lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
- Large haemorrhage and significant comorbidities before the stroke
- Score on GCS of below 8 (unless this is because of hydrocephalus)
- Posterior fossa haemorrhage
What is the most common site for intracerebral haemorrhagic stroke?
basal ganglia - due to hypertension causing rupture of small penetrating arteries
In addition to the basal ganglia what are 3 other sites of bleeding in ICH?
- Lobar white matter
- Pons
- Cerebellum
What is the most common management of ICH?
usually treated conservatively
What would be the surgical management of ICH, if performed?
surgical evacuation of haematoma
