378.2 🩺 國考版

378.2.1 高頻考點

378.2.1.1 ICH Etiology by Location

  • Deep (basal ganglia, thalamus, pons, cerebellum): HTN
  • Lobar (frontal, parietal, occipital, temporal): CAA in elderly, AVM/tumor in younger

378.2.1.2 Cerebellar ICH > 3 cm or Deteriorating

  • Posterior fossa decompression (life-saving)

378.2.1.3 INTERACT-3 (2023)

  • Bundled care with SBP target 140 mmHg
  • Reduced mortality + disability

378.2.1.4 STICH Trials

  • STICH-I (2005), STICH-II (2013)
  • No benefit for routine evacuation of supratentorial ICH
  • Select cases may benefit

378.2.1.5 ENRICH (2024)

  • Minimally invasive evacuation for lobar ICH
  • Improved outcomes
  • Changes practice for select lobar

378.2.1.6 Anticoagulation Reversal

Drug Reversal
Warfarin 4-factor PCC + vitamin K
Dabigatran Idarucizumab
Apixaban, rivaroxaban Andexanet alfa (ANNEXA-I 2023 controversial)
Edoxaban Andexanet (less data)
Heparin Protamine

378.2.1.7 SAH Causes

  • Aneurysm 80%
  • AVM
  • Trauma
  • Perimesencephalic
  • Vasculitis
  • RCVS
  • Cocaine

378.2.1.8 SAH Presentation

  • “Worst headache of life”
  • Thunderclap
  • LOC ~ 50%
  • Photophobia, meningismus (delayed)
  • Sentinel headache (warning bleed)

378.2.1.9 SAH Workup

  • CT (sensitive first 6 hr, ~ 100%)
  • LP if CT negative (xanthochromia)
  • CTA/DSA for aneurysm

378.2.1.10 Hunt-Hess Grades

  • I: minimal
  • II: moderate headache, no deficit
  • III: confusion, mild deficit
  • IV: stupor, moderate-severe
  • V: coma

378.2.1.11 Aneurysm Treatment

  • Coiling preferred (ISAT)
  • Clipping for select (MCA, complex, young)
  • Within 24-72 hr

378.2.1.12 Nimodipine

  • 60 mg PO q4h × 21 days
  • Reduces poor outcomes from DCI
  • Hold/halve if BP drops

378.2.1.13 Vasospasm

  • Peak day 4-14
  • TCD monitoring
  • Euvolemia + induced HTN (NOT triple-H anymore)
  • Endovascular for refractory

378.2.1.14 Hyponatremia in SAH

  • Cerebral salt wasting (CSW) > SIADH
  • Treat with salt + fluid (not restriction)

378.2.1.15 Cardiac in SAH

  • Takotsubo cardiomyopathy
  • Neurogenic pulmonary edema
  • Arrhythmias

378.2.1.16 Sentinel Headache

  • Warning bleed days-weeks before
  • Less severe
  • May be missed
  • High suspicion for SAH

378.2.1.17 Aneurysm Screening

  • 1st-degree relative + SAH
  • ADPKD + family history
  • Connective tissue disorders (rare)
  • MRA preferred

378.2.2 Specific Conditions

378.2.2.1 Cerebral Amyloid Angiopathy (CAA)

  • Elderly
  • Lobar ICH
  • Often recurrent
  • Microbleeds on T2*/SWI
  • Boston criteria
  • AVOID anticoagulation if possible

378.2.2.2 Hereditary CAA

  • Familial Dutch-type, Icelandic, others
  • Earlier onset

378.2.2.3 Aneurysm Locations

  • Anterior communicating (most common ~ 30%)
  • Posterior communicating (~ 25%) — can compress CN III (pupil-involving)
  • MCA bifurcation
  • ICA
  • Basilar tip (high morbidity)

378.2.2.4 Perimesencephalic SAH

  • Non-aneurysmal
  • Prepontine/perimesencephalic blood
  • Benign course usually
  • Negative angiogram
  • Some still get repeat angiogram