378.1 🎓 醫孞生版

378.1.0.1 📌 䞀頁重點

378.1.0.1.1 Intracerebral Hemorrhage (ICH)

378.1.1 Epidemiology

  • 10% of strokes
  • 30-day mortality 40%
  • 6-month dependency high

378.1.2 Etiology by Location

Deep (Hypertensive, ~ 60%): - Basal ganglia/putamen (most common) - Thalamus - Pons - Cerebellum

Lobar (CAA in elderly, AVM/tumor in younger): - Frontal, parietal, occipital, temporal - CAA: hereditary or sporadic (Aβ deposition in vessel walls) - Often recurrent - Microbleeds on T2*/SWI

Other: - Anticoagulation - Drug-induced (cocaine, amphetamine — usually lobar) - Tumor with hemorrhage - Venous infarct (CVST) - Hemorrhagic transformation of infarct - Trauma

378.1.3 Presentation

  • Sudden focal deficit (similar to ischemic)
  • Headache more common (~ 40%)
  • Vomiting more common
  • LOC more common
  • Higher BP
  • Seizures (5-15%)
  • Rapid deterioration

378.1.4 Diagnosis

CT Head Non-Contrast: - Hyperdense (acute blood) - Volume estimation (ABC/2 method) - Edema - Mass effect - IVH (intraventricular hemorrhage)

CTA / MRA: - Look for underlying lesion (AVM, aneurysm) - “Spot sign” predicts expansion

MRI: - T2*/SWI for microbleeds (CAA) - Edema, age of bleed

378.1.5 Acute Management

Blood Pressure: - INTERACT-3 (2023): bundled care including SBP 140 mmHg lowered mortality + disability - ATACH-2 (2016): aggressive ≀ 140 vs 140-180 — no diff in outcome but more renal adverse events - Current: target SBP 130-140 if presenting SBP 150-220; cautious lowering - IV labetalol or nicardipine

Reverse Anticoagulation: - Warfarin: 4-factor PCC (Kcentra) + vitamin K - DOACs: - Andexanet alfa for apixaban/rivaroxaban (ANNEXA-I 2023 — controversial) - Idarucizumab for dabigatran - Antiplatelet: limited evidence for platelet transfusion (PATCH trial negative)

Other: - Glucose, temperature, electrolytes management - DVT prophylaxis (mechanical first, pharmacologic after stable) - Seizure prophylaxis NOT routine - ↑ ICP management for clinical deterioration - Reverse Trendelenburg - Osmotherapy (mannitol, hypertonic saline) - Ventricular drain for IVH with hydrocephalus

Surgical: - Cerebellar > 3 cm OR clinical deterioration: posterior fossa decompression (life-saving) - STICH-I/II: routine evacuation of supratentorial ICH no benefit, but select cases (superficial, lobar) - ENRICH (2024): minimally invasive evacuation (BrainPath + Trans-LAM) improved outcomes for lobar ICH - IVH with hydrocephalus: EVD + thrombolytics (CLEAR III)

378.1.6 Prognosis

  • ICH score (0-6): age, GCS, volume, location, IVH
  • Higher score = worse mortality
378.1.6.0.1 Subarachnoid Hemorrhage (SAH)

378.1.7 Epidemiology

  • 5% of all strokes
  • Mostly age 40-60
  • Higher in women
  • Risk factors: HTN, smoking, family history (1st degree), polycystic kidney disease (ADPKD), Ehlers-Danlos IV

378.1.8 Etiology

  • Ruptured saccular aneurysm ~ 80% (Berry aneurysm)
  • Traumatic
  • AVM
  • Perimesencephalic (non-aneurysmal, prepontine, benign)
  • Vasculitis
  • RCVS
  • Coagulopathy
  • Cocaine
  • Mycotic aneurysm
  • Sickle cell

378.1.9 Presentation

  • “Worst headache of life” (thunderclap, < 1 min)
  • May follow exertion/coitus
  • Meningismus (delayed hours)
  • Photophobia
  • LOC (~ 50%) — predicts worse prognosis
  • Focal deficits (oculomotor nerve palsy from PCom aneurysm)
  • Seizures (~ 15%)
  • Vomiting
  • Sentinel headache (warning bleed, days-weeks before)

378.1.10 Examination

  • Vital signs
  • GCS
  • Pupils, eye movements
  • Cranial nerves (especially III)
  • Motor
  • Meningismus (delayed)
  • Fundoscopy (Terson syndrome: vitreous hemorrhage)

378.1.11 Diagnosis

CT Head Non-Contrast: - Highly sensitive in first 6 hours (~ 100%) - Sensitivity decreases over time - Hyperdense in basal cisterns, sulci - Fisher grading

LP if CT Negative: - Xanthochromia (yellow CSF) due to bilirubin from RBC breakdown - Most reliable 12 hr - 2 weeks after onset - Spectrophotometry preferred (more sensitive than visual inspection)

CTA / DSA: - Locate aneurysm - DSA gold standard - Plan intervention

MRI: - FLAIR sensitive - T2*/SWI

378.1.12 Grading Scales

Hunt-Hess: - I: minimal/no symptoms - II: moderate headache, no neuro deficit - III: confusion, mild deficit - IV: stupor, moderate-severe deficit - V: coma, decerebrate

WFNS (World Federation): - I: GCS 15, no deficit - II: GCS 13-14, no deficit - III: GCS 13-14, with deficit - IV: GCS 7-12, with or without deficit - V: GCS 3-6, with or without deficit

Modified Fisher: - Predicts vasospasm - Based on blood thickness + IVH

378.1.13 Acute Management

ABC + Airway (intubate if GCS ≀ 8 or deteriorating)

BP Control: - Cautious — too low → ischemia - Generally < 160 SBP before aneurysm secured - IV labetalol or nicardipine

Reverse Anticoagulation if applicable

Aneurysm Securing (Within 24-72 hr): - Endovascular Coiling (preferred for most): - ISAT trial: coiling > clipping for outcomes - Less invasive - Especially posterior circulation, elderly, poor surgical candidates - Surgical Clipping: - For complex aneurysms, large/giant, broad neck, MCA bifurcation - Younger patients - Pipeline flow diverters for select unruptured

Nimodipine: - 60 mg PO q4h × 21 days - Reduces poor outcomes from delayed cerebral ischemia (DCI) - Mechanism not fully clear (not just vasodilation) - Hold/halve if BP drops

Vasospasm Surveillance: - Peak day 4-14 - TCD monitoring - CT/CTA/MRA if clinical change - “Triple H therapy” (HTN, hypervolemia, hemodilution) — debunked; euvolemia + induced HTN if symptomatic vasospasm - Endovascular: intra-arterial verapamil, balloon angioplasty for refractory

Hydrocephalus: - Acute (obstructive from clot) - Chronic (communicating) - EVD → eventual VP shunt if persistent (~ 20%)

Other Complications: - Hyponatremia (cerebral salt wasting > SIADH; treat with salt + fluid, not restriction) - Cardiac (Takotsubo cardiomyopathy, neurogenic pulmonary edema, arrhythmias) - Seizures (1-week prophylaxis controversial) - DVT/PE - Anemia (transfuse to ≥ 9 g/dL) - Glucose control - Fever management

378.1.14 Prognosis

  • 10-15% die before reaching hospital
  • 30-day mortality 30-40%
  • Survivors: significant long-term morbidity
378.1.14.0.1 Aneurysm Screening
  • 1st-degree relative + SAH: consider screening (especially 2+ affected)
  • ADPKD with FHx
  • Specific syndromes
  • Modality: MRA preferred

378.1.14.1 🩺 床邊速查

  • ICH location → etiology: deep = HTN; lobar = CAA (elderly)
  • ICH BP: SBP 130-140 (INTERACT-3 2023)
  • ICH reversal: PCC + vitamin K (warfarin); andexanet alfa (apixaban/rivaroxaban); idarucizumab (dabigatran)
  • ICH surgery: cerebellar > 3 cm (life-saving); STICH negative for routine; ENRICH 2024 positive for lobar
  • SAH: “worst headache of life” — CT first; LP if CT-neg (xanthochromia)
  • SAH: coiling > clipping (ISAT); nimodipine 60 mg q4h × 21 days
  • Vasospasm peak day 4-14; TCD monitoring; euvolemia + HTN if symptomatic
  • Hyponatremia from CSW — treat with salt + fluid (not restriction)