378.3 🏥 內科專科考前版

378.3.1 Mechanistic Deep Dive

378.3.1.1 Charcot-Bouchard Microaneurysms

  • Lipohyalinosis from chronic HTN
  • Small penetrating arteries
  • Rupture → deep ICH

378.3.1.2 CAA Pathophysiology

  • Amyloid β deposition in vessel walls
  • Vessel fragility
  • Lobar bleeding
  • Microbleeds visible on T2*/SWI

378.3.1.3 Aneurysm Formation

  • Hemodynamic stress at bifurcations
  • Saccular (berry) most common
  • Risk factors: HTN, smoking, family history, ADPKD, vascular EDS, fibromuscular dysplasia

378.3.1.4 Vasospasm Pathophysiology

  • Multifactorial
  • Endothelin, NO depletion
  • Oxidative stress
  • Neuroinflammation
  • Cortical spreading depression
  • Microthrombosis

378.3.2 Recent Trials & Updates

378.3.2.1 INTERACT-3 (2023)

  • Care bundle (BP, glucose, temperature, anticoagulation reversal)
  • Improved outcomes
  • Lancet

378.3.2.2 ATACH-2 (2016)

  • Intensive (< 140) vs moderate (140-180) BP lowering
  • No mortality difference
  • More renal AEs in intensive

378.3.2.3 ENRICH Trial (NEJM 2024)

  • Minimally invasive ICH evacuation
  • Lobar ICH improved
  • Practice-changing for select

378.3.2.4 CLEAR III (2017)

  • Intraventricular thrombolytics for IVH
  • Modest benefit

378.3.2.5 PATCH (2016)

  • Platelet transfusion for antiplatelet-related ICH
  • Worse outcomes
  • DO NOT routinely transfuse

378.3.2.6 ANNEXA-I (NEJM 2023)

  • Andexanet alfa vs usual care for ICH on Xa inhibitors
  • ↓ hematoma expansion but more thrombotic events
  • Controversial role

378.3.2.7 ULTRA Trial (Lancet 2021)

  • Ultra-early TXA for SAH
  • No benefit on outcomes

378.3.2.8 SAHIT (2017)

  • Pooled SAH outcome prediction

378.3.2.9 Aneurysm Recurrence Trials

  • Long-term ISAT follow-up
  • Coiling has some recurrence but lower mortality

378.3.3 High-Yield Specialist Points

378.3.3.1 ICH Score (Hemphill)

  • Age ≥ 80: 1
  • GCS:
    • 5-12: 1
    • 3-4: 2
  • Volume ≥ 30 mL: 1
  • Infratentorial: 1
  • IVH: 1
  • Max 6
  • Mortality 0 → 0%; 6 → 100%

378.3.3.2 ABC/2 Method for ICH Volume

  • A × B × C / 2
  • A: longest diameter
  • B: perpendicular to A
  • C: number of slices × slice thickness
  • mL volume

378.3.3.3 Hematoma Expansion

  • 30% of ICH
  • Within first hours
  • Predictors: spot sign on CTA, volume, time, anticoagulation
  • Goal: prevent

378.3.3.4 Spot Sign

  • Contrast extravasation on CTA
  • Predicts expansion
  • Possible target for treatment

378.3.3.5 Modified Rankin Scale (mRS)

  • 0-6
  • 0: no symptoms; 6: dead
  • Outcome metric

378.3.3.6 CAA Criteria (Boston Criteria 2.0)

  • Probable, possible, definite
  • Imaging + clinical
  • Newer biomarkers

378.3.3.7 Cerebral Salt Wasting vs SIADH

  • Both cause hyponatremia
  • CSW: hypovolemic (negative fluid balance)
  • SIADH: euvolemic/hypervolemic
  • Treatment differs (CSW: fluid + salt; SIADH: restriction)
  • Important in SAH

378.3.3.8 Triple-H Therapy

  • Hypertension, hypervolemia, hemodilution
  • Older paradigm
  • Now: euvolemia + induced HTN for symptomatic vasospasm

378.3.3.9 Aneurysm Coil vs Clip Long-Term

  • ISAT 18-year follow-up
  • Coiling: more recurrence
  • But overall outcomes still favor coiling

378.3.3.10 Pipeline Flow Diverters

  • For complex aneurysms
  • Wide neck, blister, giant
  • Avoid antiplatelet bleeding

378.3.3.11 Endoluminal Devices

  • WEB device
  • Surpass

378.3.4 Pearls

  • ICH: deep (HTN) vs lobar (CAA)
  • ICH BP: SBP 130-140 (INTERACT-3 2023)
  • Reversal: PCC + vit K, idarucizumab, andexanet
  • STICH negative, ENRICH positive for lobar
  • Cerebellar ICH > 3 cm: emergency surgery
  • SAH: “worst headache” — CT then LP if neg (xanthochromia)
  • Coiling > clipping (ISAT)
  • Nimodipine 60 q4h × 21 days
  • Vasospasm peak day 4-14
  • CSW in SAH — fluid + salt
  • Sentinel headache — high suspicion
  • CAA — avoid anticoagulation if possible