Intracranial Hemorrhage Flashcards
how does vasculature guide the hemorrahgic vs intracranial stroke?
- hemorraghic strokes - DO NOT follow vassculature
- intracranial strokes - FOLLOW vasculature
identify the hemorhages shown in each location
list the vasculature most commonly involved in
- a epidural hemorrhage
- a subdural hemorrhage
- middle mengineal artery
- bridging veins
epidural hemorrhage
- precipiating circumstances
- vassculature involved
- clinical presentation
- exam
- MRI
- management
- precipitating event: trauma - often skull fracture
- vassculature involved: middle meningeal artery
- clinical: brief LOC -> lucid interval -> obtunded interval -> HA
- exam: relative to side of injury
- contralateral hemiparies
- ipsilateral pupil dilation
- MRI: bi-convex (lens shape)
- management: OR
subdural hemorrhage
- precipitating circumstances
- vasculature involved
- clinical presentation
- MRI
- management
- preceipiating event: trauma - fall in elderly w/ dementia, alcoholism
- vasculature involved: bridging veins
- clinical presentation: HA + altered awarness
- MRI: narrow, cresent shaped lesion
- management: situational
intraparenchymal hemorrhage
- precipitating circumstances
- clinical presentation
- MRI
- management:
- precipitating circumstsances
- hypertension
- trauma
- clinical presentation: progressive HA + vomitting + lethargy
- MRI: significant mass affect
- management: monitor, esp posterior fossa
subarachnoid hemorrhage
- precipitating circumstances
- clinical presentation
- MRI
- management:
- precipitating circumstances:
- anuerysm rupture - ACOM, PCOM*, MCA, PCA
- trauma
- clinical presentation: worst HA of life
- MRI: follows sulci -> can become interventricular
- management:
- prevent re-bleed
- prevent vasospasm
- endovascular coiling:
- surgical clipping of ruptured anuerysm, depending on aneurysm size
- maintaining normal water & salt volumes
which cerebral artery is
- the mostl likely site for an aneurysm?
- most likely to rupture d/t an aneurysm?
- anterior circulation (ACOM, ACA) m/c anuerysm site
- PCOM aneurysm most likely to rupture
what is the purpose of the Hunt Hess Grading Scale?
define each grade
predicts survival after an SAH
- Grade 1: no-minimal HA / slight nuchal ridigity
- Grade 2: moderate-severe HA / nuchal ridigty but no neurological deficit
- Grade 3: DROWSY + slight neurological deficit
- Grade 4: deficit = strupor + hemiparesis
- Grade 5: deficit = coma
SAH - diagnosis
- CT scan - senstive up to 12 hrs (most sensitive at 6) post event.
- xanthochromia - sensitive 2 hrs - 2 weeks post event. done to r/o false neg CT
- CT angiogram - to exclude aneurysm as cause
- MRI - to exlude vasculature malformation as a cause
SAH - prevention of re-bleeding:
what is the blood pressure goal?
SPB < 160 hrs
SAH - prevention of vasospasm
is done how?
is important why?
- done with CCBs (ex - nimodipine)
- decreases risk of delayed cerebral ischemia
why is it important to to maintain euvolemia / normonatremia in the management of SAH?
to prevent development of hypotonic hyponatremia, a common complication of SAH
if pt develops hypotonic hyponatremia: give hypertonic saline
list the common precipitating circumstances for each type of intracranial hemorrhage
- epidural: trauma - often skull fracture
- subdural: trauma - often a fall, in elderly pt with atrophy / alcoholism
- subarachnoid: trauma, aneurysm
- intraparenchyma: tumor, hypertension
list the deficits seen in a primary brain hemorrhage affecting each region:
- basal ganglia
- lobar regions
- thalamus
- pons
- cerebellum
- contralateral hemiparesis + sensory loss:
- basal ganglia: also contralateral conjugate gaze paresis
- lobar regions: also aphasia, neglect, confusion
- thalamus: also abnormal eye movements
- pons:
- quadriparesis
- facial weakness
- miosis
- decreased consciousness
- cerebellum:
- gaze paresis
- ataxia
- herniation
- gaze paresis
- coma
list the common deficits arisng from hemorrhage of the pons
- quadriplegia
- facial weakness
- miosis*
- deceased level of consciousness
list the common deficits arising from hemorrhage of the cerebellum
- gaze paresis
- ataxia
- hemorrhage
- coma
primary hemorraghe of which brain regions cause contralateral hemiparesis + sensory loss?
inddicate other deficits specific to each region
- thalamus: + abnormal eye movements
- basal ganglia: + contralateral conjugate gaze paresis
- lobar regions: +
- aphasia
- neglect
- confusion
list the hemorraghic stroke risk factors
- hypertensive vasculopathy
- cerebral amyloid angiopathy
- aneurysm / AV malformation
- women with migraine with aura
- social
- excessive EtOH
- smoking - esp if > 15 in women / > 20 in men
- cocain / amphetamines
what is the biggest risk factor for a hemorraghic stroke?
hypertensive vasculopathy
other than hypersensive vasculopathy, what is biggest risk factor for a intracranial hemorrhage?
explain
cereebral amyloid angiopathy
m/c non-traumatic cause of lobar ICH in the elerly
describe the appearance of the eye in a CN III nerve palsy
eye is down and out (abducted)
this is b/c the oculomotor nerve adducts & helps elevates
explain how to determine the cause a CN III nerve palsy based on the other abormalities present
- pupil dilated: PCOM or tumor
- pupil spared: intrinsic nerve ischemia (ex- diabetes)
how must anti-coagulants be handled in case of a re-bleed following SAH?
- reversed - esp TPA
- the exception is if the patient requires DVT prophylaxis
what are the three major types of cerebral vascular malformations?
- arteriovenous malformation
- cavernous malformation
- developmental venous anomaly
arteriovenous malformation
- describe the anatomy
- clinical presentation?
- presentation on CT?
- complications
- anatomy: arteries & veins connected w/out intervening capillary beds - often in temporal lobe
- clinical presentation: hemorrhage
- CT scan: calficications
- complications: can embolize
cavernous malformations
- describe the anatomy
- clinical presentation?
- presentation on CT?
- anatomy: vasculature made of endothelial lined caverns d/t defective tight junctions
- clinical presentation: seizure, brain hemorrhage
- CT: popcorn/mulberry appearance
developmental venous anomaly
- describe the anatomy
- clinical presentation
- anatomy: small malformation d/t focal arrest of venous development - sometimes follows intrauterine event
- clinical presentation: m/c asymptomaic
identify
arteriovenous malformation - calficiations
identify
developmental venous anomaly
identify
cavernous malformation
“popcorn / mulberry appearance” - vascular malformation of endothelial-lined caverns
