SAH and ICH 腦中的不定時炸彈 -動脈瘤 Clinical

SAH and ICH

腦中的不定時炸彈 -動脈瘤

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 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 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 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% ( 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 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 , 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 trapping + EC-IC bypass

Pre-op Post-op

Preop Angiography Postop 1 week Angiography

Endovascular therapy (coiling)

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 based on degeneration of the internal elastic lamina. Neurosurgery 40(2), February 1997, pp 403 -406

Preop angiography

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

Postop CTA

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

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

AVM related ICH

DAVF related ICH Sinus thrombosis related

DAVF related ICH

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 – 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 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 – contrast extravasation or “spot sign” on CTA – Uncontrolled blood pressure – antithrombotic therapy – Coagulopathy – End-staged renal failure, liver cirrhosis, Leukemia

Spot sign

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 –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 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

ICH score

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 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 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 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 compression • hydrocephalus due to ventricular obstruction • EVD alone not recommended

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 patients with ICH who are clinically stable

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 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 "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. 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 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 • 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

Thanks for your attention!!