Intracranial Hemorrhage Disorder Flashcards
What are the 2 most common types of intracranial hemorrhage seen in stroke & what demographics are most commonly affected by each?
- Subarachnoid hemorrhage (5-10% all strokes)
- mean age ~50 yr
- 55% men - but men predominate until 50
- Intracranial hemorrhage (10-15% all strokes)
- after 55 yr
- men > women
Identify the type of hemorrhage indicated by the black blocks show on the provided image:
What is the most common cause of a epidural hemorrhage?
traumatic, s/p skull fracture involving middle meningeal artery
What is the most common cause of subdural hemorrhage?
usually post traumatic s/p fall in elderly patient causing rupture of bridging veins
What is the most common cause of intraparenchymal hemorrhage?
hypertension, tumor
What is the most common cause of subarachnoid hemorrhage
trauma, aneurysm rupture
What areas are predisposed to having intraparenchymal hemorrhage?
basal ganglia
frontal & posterior(?) lobes
What type of hemorrhage is depicted in the provided image?
What is the classic presentation of this type of hemorrhage?
Epidural hematoma
Presentation: head trauma w/ brief loss of consciousness → lucid interval → obtunded state → headache
What is the most common location for an epidural hematoma & what findings would you expect to see on an exam?
Treatment?
temporal lobes
contralateral hemiparesis & ipsilateeral pupil dilation
treatment: operating room
What type of hemorrhage is depicted in the provided image?
What is the classic presentation of this type of hemorrhage?
Subdural Hematoma
head trauma, headache, alerted awareness
What demographics are most commonly affected by subdural hematoma & what findings would you expect to see on an exam?
Treatment?
elderly with atrophy / alcoholism
treatment: situational
What does the FUNC score estimate?
the likelihood of functional independence 90 days after diagnosis of intracranial hemorrhage
FUNC score is dependent on what variables?
blood volume
age
location of hemorrhage
Glasgow coma scale
pre-ICH cognitive impairment
Surgeons hold that operation is warranted for intracerebral hemorrhage if the blood volume is what number?
30 or more
0% of patients with a FUNC score of what number gained functional independence after 90 days?
4 or less
80% of patients with a FUNC score of what number gained functional independence after 90 days?
11
What type of hemorrhage is depicted in the provided image?
Subarachnoid (sulci have a lot of hyperdensities)
also has interventricular extension
What type of hemorrhage is depicted in the provided image?
Stroke with hemorrhagic transformation
What factors predispose someone to having a hemorrhagic stroke?
- Hypertensive vascuopathy (5x)
- cerebral amyloid angiopathy
- aneurysm / AV malformation
- esp subarachnoid
- excessive EtOH intake
- Smoking (1.5-2x)
- Illicit drugs
- cocaine / amphetamines
- Women with migraine aura
What is the most common cause of non-traumatic lobar ICH in the elderly?
cerebral amyloid angiopathy
What type of hemorrhage is depicted in the provided image?
What is the classic presentation of this type of hemorrhage?
Intraparenchymal Hemorrhage
progressive headache, lethargy, vomiting & stroke symptoms
How do vascular territories help differentiate between ischemic stroke & intraparenchymal hemorrhage?
ischemic: respect of vascular territory
intraparenchymal hemorrhage: no respect of vascular territories
What are the symptoms of a primary brain hemorrhage in the following area:
basal ganglia
contralateral hemiparesis
sensory loss
contralateral conjugate gase paresis
What are the symptoms of a primary brain hemorrhage in the following area:
lobar regions
contralateral hemiparesis or sensory loss
aphasia
neglect
confusion
What are the symptoms of a primary brain hemorrhage in the following area:
Thalamus
contralateral hemiparesis
sensory loss
abnormal eye movement
What are the symptoms of a primary brain hemorrhage in the following area:
pons
quadriparesis
facial weakness
decreased level consciousness
miosis
What are the symptoms of a primary brain hemorrhage in the following area:
cerebellum
ataxia
gaze paresis
herniation
coma
Subarachnoid hemorrhages are often caused by what?
aneurysm rupture
Where do aneurysms commonly occur? Where do aneurysms commonly rupture?
anterior communicating artery (pupillary abnormalities & extraocular movements)
Posterior circulating aneurysms have high risk of rupture
What is shown in the provided image?
saccular (berry) Aneurysm
What is the presentation of a patient with a subarachnoid hemorrhage?
“worst headache ever”
with nausea, vomiting, photophobia, neck stiffness, decreased level consciousness, ocular vitreous hemorrhage; (seizure is atypical)
What are both the modifiable & non-modifiable risk factors for subarachnoid hemorrhage?
- non-modifiable
- age, female, prior history of aneurysmal SAH, family history aneurysm in 1st degree relative, cerebral aneurysm >7mm
- modifiable
- hypertension, cigarette smoking, heavy alcohol use, sympathomimetic drug use (cocaine)
What are the two type of grading scales for subarachnoid hemorrhage?
- Hunt Hess grade (survival)
- take into account clinical status, responsiveness, & degree neurologic deficit
- Radiographic (spasm risk)
- based on radiographic imaging
- important for plan or care
If a SAH is suspected, but the CT is negative, what should you do?
- lumbar tap to look for xanthochromia (collected in 4 separate tubes)
- seen 12 hr after SAH develops
- absent after 14 days
- CT angiogram to exclude aneurysm
- MRI to evaluate possible vascular malformation
CT is 98-100% sensitive for SAH when performed within what timeframe?
12 hrs
Eye pointing “down & out” is indicative of what nerve palsy?
In what situations is the pupil dilated & in what situations is is spared?
CN III
- dilated
- PCOM aneurysm vs. tumor
- spared
- intrinsic nerve ischemia (ie. diabetes)
What are the goals of treatments for SAH?
- Prevent-re-bleeding
- prevent vasospasm
- endovascular coiling
- maintain euvolemia
- maintain normla intracranial pressure
How do we prevent rebedding in patients with SAH? When is the highest risk of this happening?
systolic blood pressure <160mmHg
first 6 hrs
How do we prevent vasospasm in patient with SAH? Why do we want to prevent this?
nimodipine in all patients
decreases risk of delayed cerebral ischemia (4-14 days after SAH)
Why might a person have a poor outcome in the situation of SAH?
- if don’t optimize fluid, BP, sodium
- non-optimal body temperature
- anemic
- hypoglycemia
What are the principles of critical care management?
- blood oxygen content & delivery
- fuel (glucose) content & delivery
- oxygen consumption
The complication of a hyoptonic hyopnatremic state can occur in what situations?
- SAH (⅓ all patients)
- ICH
- Massive stroke
- severe TBI
- meningitis/encephalitis
What are the complications we see in patients with SAH?
- cerebral edema
- seizures
- herniation
- neurogenic shock
- hypertension
- rebleed
- reversal anticoagulation agents
- no tPA
- exception: DVT prophylaxis
Why might you get a MRI if you see hyperdensity on CT of the head?
to see the arteriovenous malformations that are present in 0.1-0.2% of population
What is arteriovenous malformation & why can it be a problem?
fistulous connections of arteries & veins without normal intervening capillary beds
40% intracerebral hemorrhage in patients 15-45 due to AVM
presentation is hemorhhage/seizures
What are cavernous malformations & why can they cause a problem?
vascular malformations composed of endothelial-lined caverns; endothelia has defective tight junctions which can leak
may co-exist with developmental venous anomaly
present with brain hemorrhage / seizures
Patients with cavernous malformations are more at risk of rupture with what additional predisposing conditions?
How does a cavernous malformation appear on imaging?
if located in brainstem in a female with multiple other CM
popcorn/mulberry appearance
What is the main cause of developmental venous anomolies?
via intrauterine event resulting in focal arrest of venous development
rarely symptomatic
What can reduce morbidity & mortality in subarachnoid hemorrhage & intracerebral hemorrhage?
early surgery & critical care management
