ICH
Notes
-IPH, avoid "hemorrhagic stroke"
-15% of strokes
-40% 1y survival & 40% functional-independent at 3 mo
Initial evaluation
-ABCs 1st; initial BP
>HA, N/V, depressed status→ ICH
-STAT CTH ± CTA
>s/f spot sign
>Calculate vol (AxBxC/2)
-CBC, PT/INR, PTT, UDS
-NSGY consultation
Acute Management
-Prevent hematoma expansion
>Reversal AC
>Hold antithrombotics
PATCH trial→ NO platelets, worse outcome
>BP control
-If init BP > 160s→ target < 160s
If < 160s→ target < 140s
-Repeat CTH 4–6 hours (sooner, if neuro-chx)
-ASM, more important, if traumatic (LVT 7d)
Hx of trauma?
No, continue (spontaneous ≠ traumatic)
*Traumatic is MCC of ICH
>Ant&Post temp & inf frontal lobes contusions
>Multicompartmental
Location
ICH involves:
-IPH (cortical vs subcortical)
-SAH & IVH
-SDH & epidural
Spontaneous IPH, cause?
-SMASH-U
>Structural, Med, Amyloid (CAA), Syst disease, HTN, Undetermined
-HTN vs CAA
>BP at arrival
>Cortical vs subcortical
>bMRI w/ w/o contrast
>Repeated bMRI→ 3 mo (blood reabsorption)
HTN
-Deep (BG, Brainstem, Cerebellum, Thalamus)
-↑BP at arrival
-TTE→ s/f HTN signs (if no BP)
CAA
-Lobar
-Boston criteria 2.0
-Avoid anti-platelet & AC
Other Causes
¹Coagulopathy
(tPA/TNK>AC>TTP)
²AVM
>rep bMRI 3 mo; if no bMRI→ DSA
³Cavernoma
⁴Aneurysm
⁵Hemorrhagic tumor
>↑Risk: melanoma
>MCC: lung CA mets
>rep bMRI 3 mo
⁶Hemorrhagic transformation
>12% of all AIS in CTH, and 30% in bMRI
-Consider, EVD, if: GCS<9 or hydrocephalus
-SOC- & DHC-watch
>SOC→ >3 cm
-Hematoma evacuation
Considerations
-Statins
>SPARCL trial→ okay to continue, but do NOT newly start
-Antiplatelets
>Can be resumed, 48h post-stable CTH
-AC
>If spontaneous, no clear CAA→ wait 2 month
>if CAA→ risk > benefit; do LAAL
SAH
Classifications
>Hunt & Hess→ SAH only
>Modified Fisher→ SAH only (vasospasm risk)
0 = Noth→ Lowest
1 = Thin→ Low
2 = Thin + IVH→ Intermediate
3 = Thick→ High
4 = Thick + IVH→ Highest
>Fisher→ Amount of blood only
1 = nothing
2 = Thin
3 = Thick
4 = IVH/ IPH
Clinical clue
-When seeing infarct - consider vasospasm and adjust nimodipine dose
Therapy
Irraflow system
- continous irrigation
SDH vs Epidural
-Banana (SDH) vs lemon (epidural)
-Lemon needs acute NSGY intervention