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Intracranial Hemorrhage

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Intracranial Hemorrhage Intracranial Hemorrhage MARK MOSS, M.D. INTERVENTIONAL NEURORADIOLOGY WASHINGTON REGIONAL MEDICAL CENTER Definitions Stroke Clinical syndrome of rapid onset deficits of brain function lasting more than 24 hours or leading to death Transient Ischemic attack (TIA) Clinical syndrome of rapid onset deficits of brain function which resolves within 24 hours Epidemiology Stroke is the leading cause of adult disabilities 2nd leading cause of death worldwide 3rd leading cause of death in the U.S. 800,000 strokes per year resulting in 150,000 deaths Deaths are projected to increase exponentially in the next 30 years owing to the aging population The annual cost of stroke in the U.S. is estimated at $69 billion Stroke can be divided into hemorrhagic and ischemic origins 13% hemorrhagic 87% ischemic Intracranial Hemorrhage Collective term encompassing many different conditions characterized by the extravascular accumulation of blood within different intracranial spaces. OBJECTIVES: Define types of ICH Discuss best imaging modalities Subarachnoid hemorrhage / Aneurysms Roles of endovascular surgery Intracranial hemorrhage Outside the brain (Extra-axial) hemorrhage Subdural hematoma (SDH) Epidural hematoma (EDH) Subarachnoid hematoma (SAH) Intraventricular (IVH) Inside the brain (Intra-axial) hemorrhage Intraparenchymal hematoma (basal ganglia, lobar, pontine etc.) Your heads compartments Scalp Subgaleal Space Bone (calvarium) Dura Mater thick tough membrane Arachnoid flimsy transparent membrane Pia Mater tightly hugs the brain surface Brain Ventricles • The extradural (epidural) space is a potential space between the calvarium and the dura mater. • Subdural space- potential space between the dura and arachnoid membrane • Subarachnoid space- relatively large space which is filled with CSF Intracranial hemorrhage Extra-axial hemorrhage Subdural hematoma (SDH) Epidural hematoma (EDH) Subarachnoid hematoma (SAH) Intraventricular (IVH) Intra-axial hemorrhage Intraparenchymal hemorrhage (basal ganglia, lobar, pontine ect) Subdural Hematoma Source of bleed: stretching and tearing of bridging cortical veins. Rarely caused by an arterial hemorrhage As blood accumulates, pressure on the brain increases. This mass effect causes a subdural hematoma's symptoms. Much slower to develop into a mass large enough to produce symptoms Cause: acceleration-deceleration injury (trauma) Risk factors: Elderly, dementia, alcoholics, pts on anticoagulation Subdural Hematoma • Clinical features: HA, fluctuating LOC, confusion, dilated fixed pupil, gaze deviation, can have high mortality Not a Aneurysm Treatment options Medical managent Neurosurgical Burr hole irrigation Craniotomy Intracranial hemorrhage Extra-axial hemorrhage Subdural hematoma (SDH) Epidural hematoma (EDH) Subarachnoid hematoma (SAH) Intraventricular (IVH) Intra-axial hemorrhage Intraparenchymal hemorrhage (basal ganglia, lobar, pontine ect) Epidural Hematoma Traumatic Intracranial bleed A neurologic emergency Bleed usually arterial but rarely can be venous Clinical Features: LOC>>>Lucid Interval>>unconsciousness s/s of raised ICP / cerebral herniation Focal neurological deficit Epidural hematoma Typically epidural hematomas are seen in young trauma patients Usually have a skull fracture (80%) Classically a torn meningeal artery (middle meningeal artery) Convex appearance Epidural Hematoma Treatment options Surgical emergency craniotomy Intracranial hemorrhage Extra-axial hemorrhage Subdural hematoma (SDH) Epidural hematoma (EDH) Subarachnoid hematoma (SAH) Intraventricular (IVH) Intra-axial hemorrhage Intraparenchymal hemorrhage (basal ganglia, lobar, pontine ect) Intraventricular Hemorrhage Blood within the ventricular system Usually from extension of aneurysmal subarachnoid hemorrhage or hypertension-related intracerebral hemorrhage Less likely etiologies Vascular malformations, anticoagulation, intraventricular tumor trauma Most immediate threat to life is the development of obstructive hydrocephalus. Mainstay of treatment is a External ventricular drain (EVD) Intracranial hemorrhage Extra-axial hemorrhage Subdural hematoma (SDH) Epidural hematoma (EDH) Subarachnoid hematoma (SAH) Intraventricular (IVH) Intra-axial hemorrhage Intraparenchymal hemorrhage (basal ganglia, lobar, pontine ect) Intraparenchymal Hematoma Clot is located within the substance of the brain Can extent to surface(SAH,SDH) or (IVH) Spontaneous intracerebral hematoma often the result of uncontrolled hypertension or amyloid angiopathy Underlying pathology (vascular malformation, tumor) Trauma Intra-parenchymal Hematoma Treatment options Clot evacuation Intracranial hemorrhage Extra-axial hemorrhage Subdural hematoma (SDH) Epidural hematoma (EDH) Subarachnoid hematoma (SAH) Intraventricular (IVH) Intra-axial hemorrhage Intraparenchymal hemorrhage (basal ganglia, lobar, pontine ect) Subarachnoid Space Contains larger cerebral blood vessels that penetrate into and out of brain parenchyma Contains cerebrospinal fluid (CSF) When these blood vessels tear or rupture they release blood into the subarachnoid space where it mixes with CSF. • Occasionally this blood can extend into the: brain parenchyma 20-40% • Extend into the ventricles 13-28% • Or into the subdural space 2-5% Subarachnoid Hemorrhage Etiology Trauma (most common) Spontaneous SAH Aneurysms 75-80% (aSAH) Arteriovenous malformations (AVM) 4-5% Vasculopathy / Vasculitis / RCVS Arterial dissection Coagulopathy Spinal AVM Drugs (cocaine , amphetamines) Sickle cell disease Pituitary apoplexy Benign perimesencephalic hemorrhage Unknown 15% Possible Risk Factors for SAH NON-MODIFIABLE MODIFIABLE • Age • HTN • Sex • Cholesterol • Race • Anti-coagulation • Asians>Afr. Amer.>White • Anti-platelets • Genetic • Smoking • Cerebral amyloid angiopathy, • High ETOH intake coagulation disorders • DM • Drugs (cocaine, amphetamines) Aneurysmal Subarachnoid Hemorrhage Trauma (most common) Spontaneous SAH Aneurysms 75-80% Arteriovenous malformations (AVM) 4-5% Vasculopathy / Vasculitis / RVCS Arterial dissection Coagulopathy Spinal AVM Drugs (cocaine , amphetamines) Sickle cell disease Pituitary apoplexy Benign perimesencephalic hemorrhage Unknown 15% What is a brain aneurysm ? Area of weakness in a brain blood vessel that over time can grow larger and thinner. Aneurysms are dangerous because they eventually rupture allowing blood to leak out of the vessel and cause a SAH. Aneurysm Definition A abnormal dilation of a blood vessel. Saccular 90%, fusiform, dissecting and mycotic Giant aneurysm (>25mm) Wide neck aneurysm is defined as a Fundus: neck ratio <1 or a neck greater than 4 mm. Aneurysm Incidence and Demographics Approximately 2-3% of the population have a intracranial aneurysm 10-12 million people in the U.S. Vast majority of aneurysms are asymptomatic 30,000 ruptured aneurysms a year in US 20% incidence of multiple aneurysms in those with aneurysms Estimated rate of aneurysmal SAH is 6-8/100,000 Peak age of aneurysm rupture is 55-60 Female>Male Aneurysm Biology What causes Brain Aneurysms? In most cases, the reason why aneurysms form is unclear. Intracranial arteries are relatively fragile with less muscle, elastic protein and thinner walls than that of peripheral arteries of a similar size. Intracranial arteries have less supporting tissues surrounding them. Aneurysms most often form at bifurcations where there is turbulent flow and stress. Congenital defects in the media layer of the arterial wall ? Infection and inflammation can cause weakening of the arterial wall. Trauma Aneurysm Formation Summary “Complex disease”, where some things are known to contribute to aneurysm formation: smoking, chronic high blood pressure, chronic alcohol abuse, illicit drug use, and genetic factors. They are acquired lesions, which is supported by the fact that aneurysm prevalence increases with increasing age Smoking and hypertension are major drivers in the formation and progression of aneurysms and thereby a target for therapeutic intervention Exact etiology of aneurysm formation remains uncertain Risk factors for Aneurysms Polycystic Kidney Disease (15% have aneurysms) Fibromuscular Dysplasia Atherosclerosis AVM Moya-moya Marfan’s syndrome Connective tissue disorder (Ehlers-Danlos) Bacterial endocarditis Smoking Familial aneurysms risk (at least 1 first-degree family member with an intracranial aneurysm, and especially if 2 first- degree relatives are affected) and family history of a SAH 80% aneurysms arise from the COW Why are Aneurysms Dangerous? Size and location are the most important factors that determine the likelihood that an aneurysm will rupture Small aneuryms <5mm are unlikely to rupture and are often not treated unless they begin to grow. The larger an aneurysm is the more likely it will rupture. Aneurysms located in the back half of the brain (vertebral arteries, basilar artery, and the posterior communicating artery) are higher risk than aneurysms found in the anterior half (carotid artery, middle cerebral artery, and the anterior cerebral artery) Other risk factors for rupture: Growth, multiple aneurysms, prior rupture, symptomatic aneurysms, irregular shape, and family history of ruptured aneurysms. Natural History of Aneurysmal SAH 10-15% die before reaching a hospital 10% die within first several days of reaching care Overall mortality is 32-67% for all comers 30% of survivors have significant disability
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