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Acute Care I > Neuro Emergencies: Intracerebral Hemorrhage > Flashcards

Neuro Emergencies: Intracerebral Hemorrhage Flashcards

1
Q

Small Vessel Disease Types
Arteriolosclerosis what is it and where does it affect?

A

Concentric hyalinized vascular wall thickening favoring the penetrating arterioles of the basal ganglia, thalamus, brainstem, and deep cerebellar nuclei

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2
Q

Small Vessel Disease Types
Arteriolosclerosis
Risk Factors

A

HTN
DM
Age

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3
Q

Small Vessel Disease Types
Cerebral Amyloid Angiopathy (CAA) What is it and where does it affect?

A

Deposition primarily of the Beta-amyloid peptide in the walls of arterioles and capillaries in the leptomeninges, cerebral cortex, and cerebellar hemispheres

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4
Q

Small Vessel Disease Types
Cerebral Amyloid Angiopathy (CAA)
Risk Factors

A

Age
apolipoprotein E genotypes containing the ε2 or ε4 alleles

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5
Q

Mechanisms of ICH - Related Brain Injury
Direct pressure effects what?

A

Local compression of immediately surrounding brain parenchyma
Perilesional edema
Increase ICP
Hydrocephalus
Herniation
Hematoma Expansion

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6
Q

Mechanisms of ICH - Related Brain Injury
Secondary physiological and cellular pathways

A

Biochemical toxicity of blood products such as hgb, iron and thrombin (exact mechanism is unknown)
Cerebral edema
Inflammation

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7
Q

Typical Hypertensive ICH Locations
50% occur where?
35% occur where?
10% occur where?
6% occur where?

A

deep
lobar
cerebellar
brainstem

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8
Q

ICH risk factors include?

A

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

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9
Q

ICH vascular risk factors include?

A

Ischemic stroke
Prior ICH
HTN
DM
Metabolic Syndrome
HLD
Imaging biomarkers

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10
Q

Clinical Manifestations of ICH include?

A

HA common but not always present
N/V
Onset of sudden focal deficit w/ or w/o progression
AMS
ECG changes

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11
Q

Clinical Evaluation of ICH includes?

A

ABCs
Neuro assessment
Physical Exam
Onset/Last known normal
Focused Hx

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12
Q

Clinical Evaluation of ICH
Focused Hx includes?

A

PMH
Medications
Cognitive impairment or dementia
Social hx (substance abuse)
Liver disease, uremia, malignancy and hematologic d/o

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13
Q

Clinical Evaluation of ICH
Labs to order include?

A

CBC
PT/INT & aPTT
CMP
blood glucose
troponin
ECG
Tox screen
ESR
CRP
pregnancy test

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14
Q

Clinical Evaluation of ICH
Specific test for DOACs?

A

dilute thrombin time
anti-Xa activity

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15
Q

Clinical Evaluation of ICH
Imaging?

A

Head CT or MRI
CTA w/n first few hrs may be reasonable to identify pts at risk for hematoma expansion

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16
Q

CTA plus consideration of CTV or MRI w/ MRA is recommended in which patient populations?

A

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

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17
Q

CTA plus consideration of CTV or MRI w/ MRA is used to evaluate for what?

A

macrovascular cause including:
AVM
aneurysm
dural arteriovenous fistula
cavernoma
cerebral venous thrombosis

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18
Q

Clinical Evaluation
Digital Subtraction Angiography should be used in patient w/?

A

spont. IVH and no detectable parenchymal hemorrhage
spont. ICH and a CTA or MRA suggestive of macrovascular causes

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19
Q

Clinical Evaluation
Initial scans should measure what?

A

Initial ICH volume

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20
Q

ICH Volume
How to Calculate
AxBxC/2
A=?
B=?
C=?

A

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

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21
Q

How to Calculate an ICH score?

A

Add points from:
GCS score at presentation
ICH volume
IVH
Origin of ICH
Age

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22
Q

ICH Score
GCS score at presentation
13-15 =?
5-12 =?
3-4 =?

A

0
1
2

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23
Q

ICH Score
ICH volume (cm3)
>/=30 =?
<30 =?

A

1
0

24
Q

ICH Score
IVH
Yes =?
No =?

A

1
0

25
Q

ICH Score
Origin of ICH
Infratentorial =?
Supratentorial =?

A

1
0

26
Q

ICH Score
Age
>/= 80 =?
<80 =?

A

1
0

27
Q

ICH Management
Acute Blood Pressure lowering
Careful titration should be used to ensure what?
Should avoid what?
Initiate treatment wi/n what timeframe? reaching target w/n how long?

A

continuous smooth and sustained control of BP
Avoid peaks and large variability in SBP
2hrs of onset of ICH; 1hr

28
Q

ICH Management
Acute Blood Pressure lowering
For ICH patient presenting w/ SBP between 150 and 220 mmHg acute lower of SBP to a target of what is safe?

A

140 mmHg w/ a goal of maintaining SBP 130-150 mmHg

29
Q

ICH Management
Acute Blood Pressure lowering
In patients w/ mild to moderate ICH presenting w/ SBP > 150 mmHg, acute lowering to what SBP is potentially harmful?

A

< 130 mmHg

30
Q

Management of Anticoagulation Reversal
Warfarin
For patients requiring large volume resuscitation consider what?
Reversal agent and dose?
reversal based on INR?

A

FFP 15-20mL/kg
Vitamin K 10mg IVPB
4 factor PCC based on INR

31
Q

Management of Anticoagulation Reversal
Warfarin
4-factor PCC based on INR, dosage for:
INR 2-3.9
INR 4-6
INR >6

A

25 u/kg (max 2500u)
35 u/kg (max 3500u)
50 u/kg (max 5000u)

32
Q

Management of Anticoagulation Reversal
DOACs
Factor Xa inhibitors get reversed w/?

A

PCC 50 u/kg (max 5000u)
Andexant alpha

33
Q

Management of Anticoagulation Reversal
DOACs
Direct thrombin inhibitors get reversed w/?

A

Activated charcoal 50g (if last dose w/n 2hrs)
Idarucizumab 5g IVP

34
Q

Management of Anticoagulation Reversal
Heparin or LMWH get reversed w/?

A

Protamine 1mg for each 100 u of heparin admin in the last 2 hr (max dose 50mg)
Protamin 1 mg for each 1 mg of Enoxaparin (max 50mg)

35
Q

Management of Anticoagulation Reversal
Factor VIIa provides a reduction in?
Clinical outcome differences?
Risk of?

A

hematoma expansion
no difference
thromboembolic events

36
Q

Management of Anticoagulation Reversal
Dabigatran
Taken w/n 2 hrs?
Is Idarucizumab available:
Yes?
No?

A

Activated charcoal 50 g
Yes - give 5g IVP
No - PCCs or aPCC and or renal replacement therapy

37
Q

Management of Anticoagulation Reversal
Factor Xa - inhibitors
Taken w/n 2 hrs?
Is andexanet alfa available:
Yes?
No?

A

Activated charcoal 50 g
Yes - give it
No - 4 Factor PCC or aPCC

38
Q

Anitplatelet-Related Hemorrhage
Pt w/ spont. ICH being treated w/ ASA who require emergency surgery, what might be considered?

A

platelet transfusion

39
Q

Anitplatelet-Related Hemorrhage
Pt w/ spont. ICH being treated w/ ASA not scheduled for emergent neurosurgery platelet transfusions are what?

A

potentially harmful and should not be administered

40
Q

General Inpatient Management
Prompt transfer to ICU/SDU should be initiated for what?

A

Neuro assessments
Intubation if indicated
Analgesia if indicated
Cardiac monitoring
SMART consult
NSGY consult

41
Q

General Inpatient Management
Treatment of elevated ICP includes

A

Simple measures
Aggressive measures
1. Hyperosmolar therapy
2. EVD placement (hydrocephalus, thrombolytic)
3. Hematoma Evac

42
Q

Surgical treatment
Which patient should undergo surgical removal of cerebellar hemorrhages?

A

Cerebellar hemorrhages w/ neurologic deterioration
brainstem compression and/or hydrocephalus from ventricular obstruction
have cerebellar ICP > 15mL

43
Q

Surgical treatment
Supratentorial hematoma evac in deteriorating pts might be considered as a life-saving measure when ICH volume =? or GCS is what?

A

> 20-30 mL
5-12

44
Q

Surgical Treatment
DC w/ or w/o hematoma evac might reduce mortality for patient w/ what?

A

supratentorial ICH who are in a coma
have large hematomas w/ significant midline shift
have elevated ICP refractory to medical management

45
Q

General Inpatient Management
Glucose Control Goals

A

Treat hypoglycemia (<40-60 mg/dL)
Maintain BG < 180 mg/dL

46
Q

General Inpatient Management
Fever control should target a temp > what?

A

37.5*C

47
Q

General Inpatient Management
When should steroids be used?

A

NO STEROIDS

48
Q

General Inpatient Management
When to give Anti-Seizure Medications?

A

Treat clinical and electrographic seizures
No prophylactic AEDs

49
Q

General Inpatient Management
Prior to discharge BP should be lowered to what? and why?

A

130/80 mmHg
to prevent hemorrhage recurrence

50
Q

General Inpatient Management
When should rehabilitation start?

A

Early (24-48 hrs after onset)

51
Q

General Inpatient Management
Screenings to consider?

A

Dysphagia
Depression/Anxiety
Cognitive

52
Q

General Inpatient Management
DVT prophylaxis should include?

A

SCDs
No graduated compression stockings
UFH or LMWH 24-48 hrs from onset
IVC for DVT

53
Q

General Inpatient Management
Consider long term antithrombotic therapy in patients with?
What to consider?
May be safe when?

A

A-fib/DVT/Mechanical valve/LVAD
Risk vs Benefit
2-8 wks after ICH

54
Q

General Inpatient Management
Avoid regular long-term use of what?

A

NSAIDs

55
Q

General Inpatient Management
In pts w/ spont. ICH and an established indication for statin pharmacotherapy, the risk and benefits of statin therapy on ICH outcomes and recurrence relative to overall prevention of cardiovascular events are what?

A

uncertain

Acute Care I (15 decks)

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