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SAH and ICH SAH and ICH

腦中的不定時炸彈 -動脈瘤 腦中的不定時炸彈 -動脈瘤

Clinical Presentations of SAH • Headache – 97% – sudden onset – Sentinel hemorrhage 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)

Diagnosis of SAH • Misdiagnosis rate- 64% before 1985, now 12% • Sensitivity of Diagnosis of SAH • Misdiagnosis rate- 64% before 1985, now 12% • Sensitivity of CT for SAH: 98 -100% 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-class 1, level of evidence B • MRA, CTA-can be considered when angiography can’t be performed in a timely manner

Fischer scale ( SAH CT grading) Grade Description 1 No clot seen on CT 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 (<1 mm thickness) 3 厚層瀰漫性蜘蛛網出血及局部血塊 (>1 mm thickness) 4 腦出血或腦室出血 , 有或無瀰漫性蜘 蛛網出血

Hunt and Hess grading system for patients with SAH (Clinical grading) Grade Neurologic status Hunt and Hess grading system for patients with SAH (Clinical grading) Grade Neurologic status Mortality(%) 1 Asymptomatic or mild headache and slight nuchal rigidity 1 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 5 Coma, decerebrate posturing 77

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% 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

Initial management concerns • Clinical salvageable or not? • Hydrocephalus • Determining source of 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

Treatments for Intracranial Aneurysms Considerations: 1 condition of patient 2 aneurysm- location, size , Treatments for Intracranial Aneurysms Considerations: 1 condition of patient 2 aneurysm- location, size , shape 3 ability of surgeon and interventionalist   Microsurgery or Endovascular Tx ?

Micorsurgery of Intracranial Aneurysm 1. clipping 2. wrapping 3. proximal ligation 4. trapping or Micorsurgery of Intracranial Aneurysm 1. clipping 2. wrapping 3. proximal ligation 4. trapping or trapping + EC-IC bypass

Pre-op Post-op Pre-op Post-op

Preop Angiography Postop 1 week Angiography Preop Angiography Postop 1 week Angiography

Endovascular therapy (coiling) Endovascular therapy (coiling)

Limitations of Endovascular Treatment • Large or Giant aneurysm • Very small aneurysm • 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

 • The blister-like aneurysm appeared to be a laceration of the carotid wall • 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 403 -406

Preop angiography Preop angiography

Treatment plan • • Clipping (direct) Wrapping clipping Coiling with stent assistance Balloon test Treatment plan • • Clipping (direct) Wrapping clipping Coiling with stent assistance Balloon test occlusion – Trapping – EC-IC bypass + trapping

Postop CTA Postop CTA

ICA dorsal wall aneurysm • ICA dorsal wall aneurysm – Fragile – Difficult to ICA dorsal wall aneurysm • ICA dorsal wall aneurysm – Fragile – Difficult to clip directly – High risk of amputation • Trapping with/without revascularization is suggested

Intracerebral Hemorrhage Intracerebral Hemorrhage

Hypertensive Spontaneous ICH • • • Putamen Thalamus Cerebellum Pons Lobar hemorrhage Hypertensive Spontaneous ICH • • • Putamen Thalamus Cerebellum Pons Lobar hemorrhage

AVM related ICH AVM related ICH

DAVF related ICH Sinus thrombosis related DAVF related ICH Sinus thrombosis related

DAVF related ICH DAVF related ICH

Risk factors for poor outcomes • • Initial ICH volume and level of consciousness 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

Initial ICH volume • Important prognostic indicators • predictors of 30 -day mortality – Initial ICH volume • Important prognostic indicators • predictors of 30 -day mortality – An ICH ≥ 60 cm 3 on initial CT and a Glasgow coma scale ≤ 8 - 91%. – An ICH volume ≤ 30 cm 3 and a Glasgow coma scale ≥ 9 19%.

Early neurologic deterioration • Early neurologic deterioration within 48 hours after ICH onset is 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

Hematoma growth • within the first 24 hours • Risk factors for hematoma enlargement 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

Spot sign Spot sign

Spot sign on CTA Initial CT and CTA Immediate post-CTA 6 -hr CT Spot sign on CTA Initial CT and CTA Immediate post-CTA 6 -hr CT

Preceding antithrombotic use • Oral anticoagulants –a mortality rate of 52%- 73% after ICH 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)

Cerebral perfusion pressure (CPP) • CPP = MAP–ICP ✴MAP (mean arterial pressure) = Diastolic 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 mm. Hg

Recommended guideline for treating elevated BP in Spontaneous ICH Recommended guideline for treating elevated BP in Spontaneous ICH

ICH score ICH score

The ICH Score and 30 -day mortality. Hemphill J et al. Stroke 2001; 32: The ICH Score and 30 -day mortality. Hemphill J et al. Stroke 2001; 32: 891 -897 Copyright © American Heart Association, Inc. All rights reserved.

Seizure prophylaxis and Tx • risk of seizures in patients with spontaneous ICH ranges 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)

Control IICP • Elevate the head of the bed to 30 degrees • Analgesia 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

IICP Management • ICP monitor: patients with GCS <8 • IICP management – Osmotic 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 Pa. CO 2 of 25 - 30 mm. Hg

Surgery • Supratentorial hemorrhage — controversial; >30 m. L within 1 cm of the Surgery • Supratentorial hemorrhage — controversial; >30 m. L 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.

Surgery • Cerebellar hemorrhage • ≥ 3 cm in diameter • deteriorating, • brainstem Surgery • Cerebellar hemorrhage • ≥ 3 cm in diameter • deteriorating, • brainstem compression • hydrocephalus due to ventricular obstruction • EVD alone not recommended

Intraventricular hemorrhage • risk for hydrocephalus, especially if the third and fourth ventricles are Intraventricular hemorrhage • risk for hydrocephalus, especially if the third and fourth ventricles are involved.

Early Mobilization and rehabilitation? • Yes!! • Early mobilization and rehabilitation are suggested in Early Mobilization and rehabilitation? • Yes!! • Early mobilization and rehabilitation are suggested in patients with ICH who are clinically stable

Resumption of antiplatelet therapy • probably safe • BP is well controlled • indication 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

Resumption of antiplatelet therapy • Meta-analyses suggest that aspirin use is associated with a 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

Resumption of antiplatelet therapy • not recommend for 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

Timing and dose • There is risk hematoma expansion in the first several hours. 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 160 mg daily) is both effective and safer than higher doses.

Resumption of anticoagulation • not been definitively answered • Intravenous heparin may be safer 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 therapeutic range.

Recurrence • 5 percent of patients within two years of the first hemorrhage • 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

MRI susceptibility-weighted image (SWI) sequence MRI susceptibility-weighted image (SWI) sequence

Thanks for your attention!! Thanks for your attention!!