Intracerebral hemorrhage

Question 1

What is the primary cause of ICH in adults?

Answer 1

72% of the time, it’s hypertension. - ruptured AVM, tumrs, anticoagulants, thrombolytic therapy, cocaine ingestion. arterial rupture is probably secondary to microaneurysms of Charcot Bouchard. ALSO see non-hypertensive causes

Question 2

What are non-hypertensive Causes of ICH?

Answer 2

VASCULAR/INFLAMMATORY: Vascular Malformations (cavernous angiomas, arteriovenous malformations) granulomatous angitis of CNS, vasculitidis Trauma: Traumatic injury Bleeding disorders GENETIC: Factor VII deficiency and hemophilia leads toICH in 3-6% of patients. IATROGENIC: Anticoagulations, fibrinolytic treatment ACQUIRED: cerebral amyloid angiopathy DRUGS: Sympathomimetic agents (amphetamine and cocaine) Autoimmune: acute leukemia is a common cause of ICH favoring the lobar white matter.

Question 3

What are typical characteristics of ICH secondary to vascular malformations?

Answer 3

smaller bleeds, slower bleeds, slower symptoms. typically caused by small AVMs or cavernous angiomas which are frequently located in the subcortical white matter. SAH suggest aneurysm or an AVM as the cause of lobar ICH

Question 4

What do vascular malformations look like on MRI?

Answer 4

pop-corn appearance/pattern of mottled bright T2 hyperdensity. old hemosiderin deposits. NOTE: slow flow cavernous angiomas typically do not fill and are silent on conventional angiography.

Question 5

What primary tumors and metastatic tumors are more likely to bleed?

Answer 5

Bleeding into tumors is rare but can account for 10% of ICH cases. Haemorrhagic intracranial metastases are considered to represent between 3-14% of all cerebral metastases (c.f. 1-3% of gliomas are haemorrhagic). MNEMONIC: MR, CT, BB melanoma renal cell carcinoma choriocarcinoma thyroid carcinoma: papillary carcinoma of thyroid has highest rate of haemorrhage lung carcinoma(sheer number of cases) breast carcinoma: as for lung hepatocellular carcinoma

Question 6

True or False. There is 90% mortality in 30 days in patients with bleeding tumors.

Answer 6

True

Question 7

What are risk factors for ICH in patients on oral anti-coagulation

Answer 7

Baseline risk of increased ICH is 8-11 fold with oral anticoagulation. Risk factors include: - advanced age - Hypertension - Old strokes - Head trauma - significant white matter disease on CT scan.

Question 8

What is the average risk of ICH in patients who received IvTPA?

Answer 8

6.4%

Question 9

What is the difference between ICH and hemorrhagic transformation?

Answer 9

Question 10

How do you differentiate between ICH and Hemorrhagic infarction?

Answer 10

1. ICH
   
   • sudden, with progression
   • prominent ICP
   • dense homogenous bleeding on CT
   • prominent mass effect
   • subcortical location
   • ring-type enhancement
2. Hemorrhagic Infarction
   
   • maximal from onset
   • absent ICP
   • spotted, mottled look on CT
   • absent or mild mass effect
   • cortical more than subcortical matter
   • gyral type enhancement
     *

Question 11

What type of staining is used to identify cerebral amyloid angiopathy? and what type of vessels does it usually involve?

Answer 11

Congo Red stain.

Deposition of amyloid is usually in cerebral vessels primarily small and medium-sized vessels.

60% pf patients older than 90 years have amyloid angiopathy.

30% of patients have progressive dementia and a 50% neuritic plaques.

Question 13

What vessels does CNS vasculitis typically affect?

Answer 13

Small to Medium arteries and veins

can occur as an extension of polyarteritis nodosa

Question 14

How soon after sympathomimetics do hemorrhages occur?

Answer 14

Within minutes to hours after drug use. Typically there are beading segments within the intracranial arteries. Decongestant use and appetite suppressants have been used in the past in young women such as phenylpropanololamine

cocaine has become the most common sympathomimetic.

Answer 15