Conference Review: SAH and ICH

Yet another great review from our Resident Dr. Anand Patel

Intracranial Hemorrhage

Epidemiology

  • 2nd most common type of stroke (behind Ischemic)
  • ~25 cases per 100,000

Causes

  • Hypertension (Most Common)
  • Aneurysm
  • septic emboli
  • drugs (cocaine, amphets)
  • bleeding disorders
  • amyloid
  • vasculitis
  • Hemorrhagic infarction (venous sinus thrombosis)
  • Neoplasm
  • Trauma

Pathophysiology (hypertension)

  • Intimal hyperplasia with hyalinosis in the vessel wall due to elevated pressures
  • Focal wall necrosis causing pseudo aneurysm formation
  • small breaks in pseudo aneurysm cause leakage blood
  • If clotting system unable to keep up, massive hemorrhage can occur.

Mechanism of Injury

  • Direct mechanical injury of expanding clot
  • Cytotoxic edema
  • Mass effect, herniation
  • Mass effect increasing ICP and reducing CPP.
  • Effects of blood product breakdown.

Risk Factors

  • Anticoagulation
  • Trauma
  • Hypertension
  • Age
  • Race
  • CKD

Clinical Presentation

  • Presentation over time as size of ICH increases (up to hours)
  • Hypertension
  • Nausea, Vomiting
  • Seizure (up to 29%)
  • Focal neuro deficits
  • AMS/Coma
  • Visual Changes/Gaze Palsy

Diagnosis

  • CT/ CTA
  • MRI
  • Repeat imaging
    • Often increase in size on serial head CTs in 6 hours
  • Labs
    • PT/INR
    • CBC/Chem
    • Drug tests(cocaine)
    • Trop

Treatment

  • Based on Grading
  • ABCs
    • PaCO2 Control
      • Prevent Hypercarbia. Goal PaCO2<38 mmHg
      • PaCO2 of 25 to 30 mmHg for hyperventilation
    • BP control <140 SBP, 110 Diastolic
      • Hydral vs Labatelol
    • Glucose control between 140 and 180
    • Reduce ICP as needed
      • Elevate Head of Bed
      • Mannitol/Hypertonic Saline
      • Hyperventilation
      • Anesthetics/pain control
    • Reverse anticoagulation
    • No AEDs unless patient has seizure
    • Neurology vs Neurosurgery vs Transfer

ICH Score – Mortality of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100 percent

  • Glasgow Coma Scale (GCS) score 3 to 4 (= 2 points); GCS 5 to 12 (= 1 point) and GCS 13 to 15 (= 0 points) (table 1)
  • ICH volume ≥30 cm3 (= 1 point), ICH volume <30 cm3 (= 0 points)
  • Intraventricular extension of hemorrhage present (= 1 point); absent (= 0 points)
  • Infratentorial origin yes (= 1 point); no (= 0 points)
  • Age ≥80 (= 1 point); <80 (= 0 points)

Neuroprotective Intubation – Goal to reduced ICP rise from intubation

  • Elevated Head of Bed until needed
  • Maximize Oxygenation
  • Blood pressure control prior to intubation
  • Meds
    • Pretreament
      • Fentanyl
      • Lidocaine
    • Induction
      • Etomidate
      • Propofol
      • Avoid Ketamine (although there is no data to support this)
    • Paralytic
      • Roc vs Sux

Subarachnoid Hemorrhage

Epidemiology

  • 10% of all strokes
  • Typically between 40-60 y.o
  • Women > Men, AA> Caucasian

Causes

  • Ruptured aneurysms
  • Trauma,
  • AVM
  • Intracranial arterial dissections,
  • Amyloid angiopathy,
  • Bleeding disorders
  • Drug Use

Risk Factors

  • Hypertension
  • Race
  • Age
  • Alcohol Use
  • Smoking
  • Drug use

Symptoms

  • “Worst Headache of Life”/ Severe headache
  • Sudden Onset
  • Sentinal Headahche
    • Sudden severe headache prior to major SAH
      • 30-50%
      • Typically 6-20 days prior
    • LOC
    • N/V
    • Meningismus
    • AMS
    • Seizure
    • Death

Diagnosis

  • CT +/- CTA within 6 hours- Highly Sensitive
    • Data suggest that CT alone is ok
    • Data suggest that community CT ok.
  • LP- If CT negative and after 6 hours
    • Can consider CT/CTA within 12 hours
    • Often conversation with patient about risk/benefit
    • Xanthochromia
    • RBC’s in tube not clearing from 1-4.
      • Traumatic Tap RBC clearing of >63% from tube 1-4,
    • RBCs >100-250 in tube 4 as absolute cutoff

Treatment

  • ABCs
  • BP Control, MAP <110. SBP <140.
  • Reversal of anticoagulation
  • Fever Control
  • ICP management
  • Glycemic control
  • Maintain Euvolemia
  • Transfuse Blood for Anemia
    • >8 Hb.
  • No prophalactic AED’s but give if seizure
  • Labwork including troponin
    • Elevated trop associated with increased mortality
  • Neurosurg/Neuro/Transfer

 

Advertisements