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NS22 Neurosurgery
Cerebrovascular Disease
Toronto Notes 2019
Location of ICH
Basal Ganglia/Internal Capsule (50%) Thalamus (15%)
Cerebral White Matter (15%) Cerebellum/Brainstem – usually pons (15%) Other (5%)
ICH Score Components
• GCS score
• ICH volume
• Presence of intraventricular hemorrhage • Infratentorial origin
• Age
Early Surgery Versus Initial Conservative Treatment In Patients With Spontaneous Supratentorial Lobar Intracerebral Hematomas (STICH-II): A Randomized Trial
Lancet 2013 382(9890): 397-408
Summary: The STICH II (international, parallel-group trial comparing early surgical hematoma evacuation within 12 hour of randomization and medical treatment vs. initial medical treatment alone) results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral haemorrhage without intraventricular haemorrhage.
Spetzler-Martin AVM Grading Scale
Intracerebral Hemorrhage
Definition
• hemorrhagewithinbrainparenchyma,accountsfor~10%ofstrokes
• candissectintoventricularsystem(IVH)orthroughcorticalsurface(SAH)
Etiology
• HTN(usuallycausesbleedsatputamen,thalamus,pons,andcerebellum)
• hemorrhagic transformation (reperfusion post stroke, surgery, strenuous exercise, etc.) • vascular anomalies
■ aneurysm, AVMs, and other vascular malformations (see Vascular Malformations, NS23) ■ venous sinus thrombosis
■ arteriopathies (cerebral amyloid angiopathy, lipohyalinosis, vasculitis)
• tumours(1%):oftenmalignant(e.g.glioblastomamultiforme,lymphoma,metastases)
• drugs(amphetamines,cocaine,alcohol,anticoagulants,etc.)
• coagulopathy(iatrogenic,leukemia,thromboticthrombocytopenicpurpura,aplasticanemia)
• CNSinfections(fungal,granulomas,herpessimplexencephalitis)
• posttrauma(immediateordelayed,frontalandtemporallobesmostcommonlyinjuredviacoup-
contrecoup mechanism)
• eclampsia
• post-operative (post-carotid endarterectomy cerebral reperfusion, craniotomy) • idiopathic
Epidemiology
• 12-15cases/100,000population/yr
Risk Factors
• increasingage(mainly>55yr) • malegender
• HTN
• Black/Asian>Caucasian
• previousCVAofanytype(23xrisk)
• bothacuteandchronicheavyalcoholuse;cocaine,amphetamines • liverdisease
• anticoagulants
Clinical Features
• transientischemicattack-likesymptomsoftenprecedeICH,canlocalizetositeofimpending hemorrhage
• gradualonsetofsymptomsoverminutes-hours,usuallyduringactivity
• H/A,N/V,anddecreasedLOCarecommon
• specificsymptoms/deficitsdependonlocationofICH
Investigations
• baselineseverityscoresuchastheICHScoreshouldbeperformedaspartoftheinitialworkup
• hyperdensebloodonnon-contrastCT
• CTAroutine,ifspotsign(contrastinthehematoma)demonstratedthereishighlikelihoodofclotgrowth
Treatment
• medical
■ decrease MAP to pre-morbid level or by ~20% (target BP 140/90) in ED
■ check PTT/INR, and correct coagulopathy
■ control raised ICP (see Intracranial Pressure Dynamics, NS4)
■ corticosteroids should NOT be used for elevated ICP in ICH
■ levetiracetam/phenytoin for seizure prophylaxis
■ followelectrolytes(SIADHcommon)
■ angiogram to rule out vascular lesion unless >45 yr, known HTN, and putamen/thalamic/posterior
fossa ICH (yield ~0%) • surgical
■ craniotomy with evacuation of clot, treatment of source of ICH (i.e. AVM, tumour, cavernoma), ventriculostomy to treat hydrocephalus
■ indications
◆ symptoms of raised ICP or mass effect
◆ rapid deterioration (especially if signs of brainstem compression)
◆ favourable location (e.g. cerebellar, non-dominant hemisphere)
◆ young patient (<50 yr)
◆ if tumour, AVM, aneurysm, or cavernoma suspected (resection or clip to decrease risk of rebleed)
■ contraindications
◆ small bleed: minimal symptoms, GCS >10
◆ poor prognosis: massive hemorrhage (especially dominant lobe), low GCS/coma, lost brainstem
function
◆ medical reasons (e.g. very elderly, severe coagulopathy, difficult location [e.g. basal ganglia,
Item
Size
Score
0-3cm 1 3.1-6.0 cm 2 >6cm 3 Location
Noneloquent 0 Eloquent 1 Deep Venous Drainage
Not present 0 Present 1
AVM grades calculated by adding the 3 individual Spetzler-Martin Scale scores from the above table. e.g. a 2 cm tumour in noneloquent location without deep venous drainage = Grade I
thalamus])