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SAH and ICH
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腦中的不定時炸彈-動脈瘤
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Clinical Presentations of SAH
Headache 97% sudden onset Sentinel hemorrhage or warning headache occur in 30-60% Meningismus- Kernig sign or Brudzinski sign Coma Occular hemorrhage- subhyaloid hemorrhage, retinal hemorrhage, and vitreous hemorrhage (Terson syndrome)
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Diagnosis of SAH Cerebral angiography-class1, level of evidence B
Misdiagnosis rate- 64% before 1985, now 12% Sensitivity of CT for SAH: % at first 12 hrs 93% at 24 hrs, 57-85% 6 days after SAH CT-always be done if SAH is part of the DDx Lumbar puncture should follow when CT is negative Cerebral angiography-class1, level of evidence B MRA,CTA-can be considered when angiography can’t be performed in a timely manner
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Fischer scale ( SAH CT grading)
Grade Description 1 No clot seen on CT scan 2 薄層瀰漫性蜘蛛網出血 (<1mm thickness) 3 厚層瀰漫性蜘蛛網出血及局部血塊 (>1mm thickness) 4 腦出血或腦室出血,有或無瀰漫性蜘蛛網出血
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Hunt and Hess grading system for patients with SAH (Clinical grading)
Grade Neurologic status Mortality(%) 1 Asymptomatic or mild headache and slight nuchal rigidity 2 Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy 5 3 Drowsy or confused, mild focal neurologic deficit 19 4 Stuporous, moderate or severe hemiparesis 42 Coma, decerebrate posturing 77
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Prognosis after aneurysmal SAH
10-15% 病人死於接受治療前 死亡率: 10 %在剛開始幾天內, 總死亡率: 45% ( 32-67%). Rebleeding:主要死亡原因, 15-20% within 2 weeks. Vasospasm (血管痙孿), death 7 %, 造成嚴重神經缺損7 %. 約30 % of survivor, 有中度至嚴重神經缺損 Patient >70 years 有較差神經學預後
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Initial management concerns
Clinical salvageable or not? Hydrocephalus Determining source of bleeding – rebleeding is the major concern Delayed ischemic neurological deficit(DIND)- usually attributed to vasospasm
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Treatments for Intracranial Aneurysms
Considerations: 1 condition of patient 2 aneurysm- location, size , shape 3 ability of surgeon and interventionalist Microsurgery or Endovascular Tx ?
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Micorsurgery of Intracranial Aneurysm
1. clipping 2. wrapping 3. proximal ligation 4. trapping or trapping + EC-IC bypass
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Pre-op Post-op
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Postop 1week Angiography
Preop Angiography Postop 1week Angiography
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Endovascular therapy (coiling)
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Limitations of Endovascular Treatment
Large or Giant aneurysm Very small aneurysm Wide base aneurysm Large aneurysmal hematoma or severe hydrocephalus Severely atherosclerotic or tortuous cerebral arteries
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The blister-like aneurysm appeared to be a laceration of the carotid wall based on degeneration of the internal elastic lamina. Neurosurgery 40(2), February 1997, pp
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Preop angiography
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Treatment plan Clipping (direct) Wrapping clipping
Coiling with stent assistance Balloon test occlusion Trapping EC-IC bypass + trapping
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Postop CTA
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ICA dorsal wall aneurysm
Fragile Difficult to clip directly High risk of amputation Trapping with/without revascularization is suggested
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Intracerebral Hemorrhage
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Hypertensive Spontaneous ICH
Putamen Thalamus Cerebellum Pons Lobar hemorrhage
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AVM related ICH
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Sinus thrombosis related ICH
DAVF related ICH Sinus thrombosis related ICH
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DAVF related ICH
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Risk factors for poor outcomes
Initial ICH volume and level of consciousness Hematoma growth and clinical deterioration Preceding antithrombotic use Other factors — Patient age overall medical health and condition
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Initial ICH volume Important prognostic indicators
predictors of 30-day mortality An ICH ≥60 cm3 on initial CT and a Glasgow coma scale ≤ 8 - 91%. An ICH volume ≤30 cm3 and a Glasgow coma scale ≥ 9 19%.
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Early neurologic deterioration
Early neurologic deterioration within 48 hours after ICH onset is not infrequent Associated with a poor prognosis Potential mechanisms include hemorrhage enlargement development of hydrocephalus perilesional edema Seizure
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Hematoma growth within the first 24 hours
Risk factors for hematoma enlargement contrast extravasation or “spot sign” on CTA Uncontrolled blood pressure antithrombotic therapy Coagulopathy – End-staged renal failure, liver cirrhosis, Leukemia
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Spot sign
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Spot sign on CTA Initial CT and CTA Immediate post-CTA 6-hr CT
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Preceding antithrombotic use
Oral anticoagulants a mortality rate of 52%- 73% after ICH In nonrandomized comparisons with those not on anticoagulation therapy: relative risks ranging from 3 to 4. Antiplatelets A systematic review studies concluded that prior antiplatelet use was associated with increased mortality (OR = 1.3)
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Cerebral perfusion pressure (CPP)
CPP = MAP–ICP MAP (mean arterial pressure) = Diastolic blood pressure + 1/3 (Systolic blood pressure –diastolic blood pressure) ICP = Intracranial pressure Keep cerebral perfusion pressure in the range of 61 to 80 mmHg
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Recommended guideline for treating elevated BP in Spontaneous ICH
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ICH score
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The ICH Score and 30-day mortality.
The ICH Score and 30-day mortality. Thirty-day mortality increases as ICH Score increases. No patient with an ICH Score of 0 died. All patients with an ICH Score of 5 died. No patient in the UCSF ICH cohort had an ICH Score of 6, although this would be expected to be associated with mortality. Hemphill J et al. Stroke 2001;32: Copyright © American Heart Association, Inc. All rights reserved.
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Seizure prophylaxis and Tx
risk of seizures in patients with spontaneous ICH ranges from 4.2% - 29% more common in lobar as compared to deep hemorrhage often nonconvulsive prophylactic use of AEDs: No (by 2010 guideline for ICH)
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Control IICP Elevate the head of the bed to 30 degrees
Analgesia and sedation, particularly in unstable, intubated patients Normal saline for maintenance and replacement fluids; hypotonic fluids are contraindicated Glucocorticoids should NOT be used
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IICP Management ICP monitor: patients with GCS <8 IICP management
Osmotic diuretics (mannitol and hypertonic saline solution) Ventricular catheter drainage of CSF Neuromuscular blockade Hyperventilation to a PaCO2 of mmHg
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Surgery Supratentorial hemorrhage — controversial; >30 mL within 1 cm of the surface. Open craniotomy Other methods include endoscopic hemorrhage aspiration, use of fibrinolytic therapy to dissolve the clot followed by aspiration, and CT-guided stereotactic aspiration. Studies of these less invasive techniques are in progress the routine evacuation of supratentorial ICH in the first 96 hours is not recommended.
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Surgery Cerebellar hemorrhage ≥3 cm in diameter deteriorating,
brainstem compression hydrocephalus due to ventricular obstruction EVD alone not recommended
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Intraventricular hemorrhage
risk for hydrocephalus, especially if the third and fourth ventricles are involved.
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Early Mobilization and rehabilitation?
Yes!! Early mobilization and rehabilitation are suggested in patients with ICH who are clinically stable
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Resumption of antiplatelet therapy
probably safe BP is well controlled indication for antiplatelet Tx is sufficiently strong potential benefit outweighs the increase in risk of recurrent ICH
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Resumption of antiplatelet therapy
Meta-analyses suggest that aspirin use is associated with a very small absolute increase in risk. In cerebral amyloid angiopathy, aspirin use may be associated with a greater risk of recurrent ICH
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Resumption of antiplatelet therapy
not recommend for "average" risk of recurrent ischemic stroke. “Average risk” hypertension, diabetes, hypercholesterolemia, and the absence of heart disease. “above average” risk Atrial fibrillation, cardiomyopathy, large vessel extracranial and intracranial stenoses, and malignancy
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Timing and dose There is risk hematoma expansion in the first several hours. At 10 days, rebleeding is unlikely. The AHA/ASA guidelines of 2006 state that antiplatelets should be discontinued for at least one to two weeks. If aspirin is used after ICH, lower dose (30 to 160mg daily) is both effective and safer than higher doses.
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Resumption of anticoagulation
not been definitively answered Intravenous heparin may be safer than oral anticoagulation. Oral anticoagulants may be resumed 3-4 wks after onset of ICH with rigorous monitoring and maintenance of INRSs in the lower end of the therapeutic range.
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Recurrence 5 percent of patients within two years of the first hemorrhage Uncontrolled hypertension the most important risk factor risk factors variably identified as associated with recurrent ICH include : Uncontrolled hypertension Lobar location of initial ICH Older age Male gender Ongoing anticoagulation Apolipoprotein E epsilon 2 or epsilon 4 alleles Greater number of microbleeds on MRI Ischemic stroke history
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MRI susceptibility-weighted image (SWI) sequence
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Thanks for your attention!!
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