Lecture 4: Hemorrhagic strokes and non-traumatic intracerebral hemorrhage

-sudden

-symptoms worsen in a short period of time

is the onset of intracerebral hemorrhage sudden or gradual?

-severe HA

-seizure

-alteration of consciousness

-increased intracranial pressure

symptoms of intracerebral hemorrhage:

-increased ICP--->intracerebral hemorrhage

blown pupils is a sign of

herniation

how come intracerebral hemorrhage can be rapidly fatal?

-hemorrhagic stroke deficits may worsen within minutes to hours

How do you differentiate an ischemic and hemorrhagic stroke?

-sudden onset, focal deficit

-HA often present

clinical features of hemorrhagic stroke:

-neuro exam

-Head CT without contrast

-lumbar puncture

-assess GP

how should you evaluate a potential hemorrhagic stroke?

high blood pressure

what is the major risk factor for primary hemorrhagic stroke?

anticoagulants, or lytics like r-tPA

what should you NOT treat a pt with a hemorrhagic stroke with?

keep blood pressure lower than for ischemic stroke (160s/mid 80s)

in treating a hemorrhagic stroke, what blood pressure should you try to maintain

neurological decompression

treatment for hemorrhagic stroke if there is an abrupt increase in pressure and worsening condition

-loss of consciousness with focal findings

-"worst head ache of life"

-subarachnoid bleeding

clinical features of an intracerebral aneurysm

Thunderclap headache

classic HA associated with intracerebral aneurysm

breathing irregularities, pupillary abnormalities (dilated/fixed), extraocular movement abnormalities

if an intracerebral aneurysm results in increased ICP, what symptoms may manifest?

subarachnoid hemorrhage on CT

White blood in cisterns and 4th ventricle

-CT without contrast

-if CT negative, lumbar puncture

-angiography may locate aneurysms >5 mm

how do you evaluate /work up a suspected intracerebral aneurysm?

aneurysm on angiogram

ID pathology

-neurosurgical aneurysm clipping or coiling for bleeding aneurysm

-seizure prevention

-medications to prevent arterial spasm

how do you treat an intracerebral aneurysm?

intubation, blood pressure monitoring and stabilization

supportive therapy recommended for intracerebral aneurysm

when the aneurysm is greater than 8mm in diameter

for an asymptomatic aneurysm, at what point do you treat with a clip or coil/

berry aneurysm

what type of aneurysm is associated with polycystic kidney disease?

berry aneurysm

-located in the circle of willis

-size varies from 2-25 mm

-usually multiple

-saccular

sudden subarachnoid hemorrhage or ICH without SAH

ruptured berry aneurysm casues

-anterior communicating artery most common

-typically at weak points of circle of willis

where do berry aneurysms most commonly occur?

Charcot-Bouchard aneurysms

what type of aneurysm?

-associated with chronic hypertension

-commonly occur in arterioles in basal ganglia, thalamus, brainstem

-when small arterioles rupture, causes a hemorrhagic stroke

charcot-bouchard pseudo-aneurysm

charcot bouchard aneurysm that is usually less than 1 mm diameter

arterial dissection

-most commonly in middle aged patients

-may be spontaneous or traumatic

can occur in any of the cerebral vessels, but carotid most common

in what artery is an arterial dissection most common?

subarachnoid hemorrhage

intracerebral dissections are associated with

arterial dissection

clinically associated with pain, headache, focal euro deficits and HORNER SYNDROME

angiogram, CTA, MRA, lumbar puncture showing blood

what can be used to diagnose an arterial dissection?

heparin, transition to coumadin

what is the initial treatment for an arterial dissection?

arterial bypass; vein grafting close to intimal flap

how do you treat an arterial dissection with persistent embolization?

-clip the involved portion of the vessel

-intra arterial balloons and grafts

-reverse flow through vertebral artery

how do you treat a vertebrobasilar and intracranial dissection?

cavernous hemangioma

venous angioma

vein-vein malformations result in

higher pressure

why are arterial malformations more likely to bleed?

seizures, HA, intracerebral hemorrhage

clinical features of vascular malformations

usually no treatment-- low risk for major bleed

how do you treat cavernous hemangiomas?

usually monitor-- low risk for major bleed

how do you treat venous angiomas?

small AVMs are more dangerous than large

what is the most dangerous type of AV malformation?

embolization, radiation, and resection

how do you treat AVMs?

-recurrent lobar hemorrhages

-petechial lobar hemorrhages

clinical features of amyloid angiopathy:

-cerebral biopsy stained for amyloid

how do you diagnose amyloid angioathy?

-no available treatment-- prognosis is grim, patients will continue to have recurrent hemorrhages

-avoid anticoagulants and anti-platelet agents that could expand hemorrhages

how do you treat amyloid angiopathy?

hemorrhagic brain tumors

-glioblastoma

-primary CNS lymphoma

-melanoma

-renal cell carcinoma

bronchogenic carcinoma

what cancer is less likely to hemorrhage but more likely to metastasize/