Neuro Emergencies: Intracerebral Hemorrhage Flashcards
Small Vessel Disease Types
Arteriolosclerosis what is it and where does it affect?
Concentric hyalinized vascular wall thickening favoring the penetrating arterioles of the basal ganglia, thalamus, brainstem, and deep cerebellar nuclei
Small Vessel Disease Types
Arteriolosclerosis
Risk Factors
HTN
DM
Age
Small Vessel Disease Types
Cerebral Amyloid Angiopathy (CAA) What is it and where does it affect?
Deposition primarily of the Beta-amyloid peptide in the walls of arterioles and capillaries in the leptomeninges, cerebral cortex, and cerebellar hemispheres
Small Vessel Disease Types
Cerebral Amyloid Angiopathy (CAA)
Risk Factors
Age
apolipoprotein E genotypes containing the ε2 or ε4 alleles
Mechanisms of ICH - Related Brain Injury
Direct pressure effects what?
Local compression of immediately surrounding brain parenchyma
Perilesional edema
Increase ICP
Hydrocephalus
Herniation
Hematoma Expansion
Mechanisms of ICH - Related Brain Injury
Secondary physiological and cellular pathways
Biochemical toxicity of blood products such as hgb, iron and thrombin (exact mechanism is unknown)
Cerebral edema
Inflammation
Typical Hypertensive ICH Locations
50% occur where?
35% occur where?
10% occur where?
6% occur where?
deep
lobar
cerebellar
brainstem
ICH risk factors include?
Anticoagulation
Bleeding d/o
Older age
Cerebral amyloid angiopathy (CAA)
AVM/Aneurysm/dural arteriovenous malformations/cavernous
Cerebral venous thrombosis
Tobaccos use
Renal or liver failure
Recent CEA
Cerebral neoplasm
ICH vascular risk factors include?
Ischemic stroke
Prior ICH
HTN
DM
Metabolic Syndrome
HLD
Imaging biomarkers
Clinical Manifestations of ICH include?
HA common but not always present
N/V
Onset of sudden focal deficit w/ or w/o progression
AMS
ECG changes
Clinical Evaluation of ICH includes?
ABCs
Neuro assessment
Physical Exam
Onset/Last known normal
Focused Hx
Clinical Evaluation of ICH
Focused Hx includes?
PMH
Medications
Cognitive impairment or dementia
Social hx (substance abuse)
Liver disease, uremia, malignancy and hematologic d/o
Clinical Evaluation of ICH
Labs to order include?
CBC
PT/INT & aPTT
CMP
blood glucose
troponin
ECG
Tox screen
ESR
CRP
pregnancy test
Clinical Evaluation of ICH
Specific test for DOACs?
dilute thrombin time
anti-Xa activity
Clinical Evaluation of ICH
Imaging?
Head CT or MRI
CTA w/n first few hrs may be reasonable to identify pts at risk for hematoma expansion
CTA plus consideration of CTV or MRI w/ MRA is recommended in which patient populations?
Pts w/ lobar spontaneous ICH and age < 70
Pt w/ deep/posterior fossa spontaneous ICH and age < 45
Pts w/ deep posterior fossa age 45-70 w/o history of HTN and signs of small vessel disease
CTA plus consideration of CTV or MRI w/ MRA is used to evaluate for what?
macrovascular cause including:
AVM
aneurysm
dural arteriovenous fistula
cavernoma
cerebral venous thrombosis
Clinical Evaluation
Digital Subtraction Angiography should be used in patient w/?
spont. IVH and no detectable parenchymal hemorrhage
spont. ICH and a CTA or MRA suggestive of macrovascular causes
Clinical Evaluation
Initial scans should measure what?
Initial ICH volume
ICH Volume
How to Calculate
AxBxC/2
A=?
B=?
C=?
A= greatest hemorrhage diameter in the axial plane
B= hemorrhage diameter at 90* to A in the axial plane
C= the number of CT slices with the hemorrhage multiplied by slice thickness
Divide by 2
How to Calculate an ICH score?
Add points from:
GCS score at presentation
ICH volume
IVH
Origin of ICH
Age
ICH Score
GCS score at presentation
13-15 =?
5-12 =?
3-4 =?
0
1
2