378.4 📋 章末速蚘 Summary

378.4.1 🔑 䞀句話瞜結

ICH (10% of strokes) = bleeding into brain parenchyma + 30-day mortality 40%; etiology by location — deep (basal ganglia/putamen most common, thalamus, pons, cerebellum) = hypertensive ~ 60% vs lobar (frontal, parietal, occipital, temporal) = cerebral amyloid angiopathy (CAA) in elderly (Aβ deposition in vessel walls, microbleeds on T2/SWI) or AVM/cavernoma/tumor in younger; other causes — anticoagulation + drug-induced (cocaine, amphetamine) + venous infarct (CVST) + hemorrhagic transformation of infarct + trauma; presentation sudden focal deficit + headache (40%) + vomiting + LOC + higher BP + seizures + rapid deterioration; diagnosis — CT head non-contrast (hyperdense acute) + ABC/2 volume method + CTA “spot sign” predicts expansion + MRI T2/SWI for microbleeds (CAA); acute management — INTERACT-3 (2023) bundled care SBP 140 mmHg lowered mortality + disability; ATACH-2 intensive vs moderate BP no diff outcome but more renal AEs; anticoagulation reversal: warfarin → 4-factor PCC (Kcentra) + vitamin K, dabigatran → idarucizumab, apixaban/rivaroxaban → andexanet alfa (ANNEXA-I 2023 controversial), antiplatelet → DO NOT routinely transfuse platelets (PATCH 2016 negative); surgical — cerebellar > 3 cm or deteriorating → posterior fossa decompression (life-saving); STICH-I/II routine evacuation supratentorial no benefit; ENRICH (NEJM 2024) minimally invasive evacuation lobar ICH improved outcomes (practice-changing); IVH with hydrocephalus → EVD ± thrombolytics (CLEAR III modest benefit); ICH score (Hemphill, 0-6) age, GCS, volume, location, IVH; SAH (5% of strokes) = bleeding into subarachnoid space; etiology — ruptured saccular aneurysm ~ 80% (anterior communicating most common ~ 30%, posterior communicating ~ 25% can compress CN III pupil-involving, MCA bifurcation, ICA, basilar tip high morbidity) + traumatic + AVM + perimesencephalic (non-aneurysmal prepontine, benign course usually, negative angiogram) + vasculitis + RCVS + coagulopathy + cocaine + mycotic + sickle cell; risk factors HTN + smoking + family history + ADPKD + Ehlers-Danlos IV + vascular fibromuscular dysplasia; presentation — “WORST HEADACHE OF LIFE” thunderclap < 1 min + may follow exertion/coitus + meningismus (delayed hours) + photophobia + LOC ~ 50% predicts worse prognosis + focal deficits (oculomotor CN III palsy from PCom aneurysm pupil-involving) + seizures 15% + vomiting + sentinel headache warning bleed days-weeks before (often missed); diagnosis — CT head non-contrast highly sensitive in first 6 hr (~ 100%, sensitivity decreases over time) + LP if CT negative (xanthochromia — yellow CSF from bilirubin RBC breakdown, most reliable 12 hr-2 weeks, spectrophotometry preferred) + CTA or DSA gold standard for aneurysm location + MRI FLAIR + T2*/SWI; Hunt-Hess + WFNS + modified Fisher grading; aneurysm securing within 24-72 hr — endovascular coiling preferred for most (ISAT trial coiling > clipping outcomes, especially posterior circulation, elderly, poor surgical candidates) + surgical clipping for complex/large/giant/broad neck/MCA bifurcation/younger + pipeline flow diverters for select unruptured; nimodipine 60 mg PO q4h × 21 days reduces poor outcomes from delayed cerebral ischemia (DCI) — hold/halve if BP drops; vasospasm peak day 4-14 — TCD monitoring + CT/CTA/MRA if clinical change + euvolemia + induced HTN if symptomatic (NOT triple-H anymore) + endovascular intra-arterial verapamil + balloon angioplasty refractory; complications — rebleeding before aneurysm secured + vasospasm + hydrocephalus (acute obstructive vs chronic communicating ~ 20% need VP shunt) + hyponatremia from cerebral salt wasting (CSW > SIADH, hypovolemic, treat with salt + fluid NOT restriction) + cardiac (Takotsubo cardiomyopathy + neurogenic pulmonary edema + arrhythmias) + seizures + DVT/PE + anemia (transfuse ≥ 9 g/dL); prognosis — 10-15% die before hospital + 30-day mortality 30-40%; aneurysm screening — 1st-degree relative + SAH (especially 2+ affected) + ADPKD with FHx + MRA preferred modality。

378.4.2 💊 治療粟芁

  • ICH BP control (INTERACT-3 2023)bundled care + target SBP 140 mmHg if presenting SBP 150-220 + IV labetalol 10-20 mg q10 min or nicardipine 5 mg/h titrate
  • ICH anticoagulation reversalwarfarin → 4-factor PCC (Kcentra) 25-50 IU/kg + vitamin K 10 mg IV + dabigatran → idarucizumab 5 g IV + apixaban/rivaroxaban → andexanet alfa (ANNEXA-I 2023, controversial) + heparin → protamine
  • ICH surgical indicationscerebellar > 3 cm or deteriorating → posterior fossa decompression (life-saving) + lobar ICH amenable to minimally invasive evacuation (ENRICH 2024) + IVH with hydrocephalus → EVD (± thrombolytics CLEAR III)
  • SAH aneurysm securing within 24-72 hrendovascular coiling preferred (ISAT) > surgical clipping for complex/MCA/young; pipeline flow diverters select
  • SAH BP control (pre-securing)generally < 160 mmHg SBP + IV labetalol or nicardipine + avoid hypotension (ischemic risk)
  • SAH nimodipine60 mg PO q4h × 21 days — reduces poor outcomes from delayed cerebral ischemia (DCI); hold or halve if BP drops
  • SAH vasospasm (peak day 4-14)TCD monitoring + euvolemia + induced HTN if symptomatic (NOT triple-H anymore) + endovascular intra-arterial verapamil/milrinone + balloon angioplasty refractory
  • SAH hyponatremia (CSW most common in SAH)hypertonic saline 3% (target Na correction not too rapid) + salt + fluid (NOT restriction unlike SIADH) + fludrocortisone 0.1-0.4 mg
  • SAH hydrocephalusexternal ventricular drain (EVD) for acute obstructive + VP shunt for persistent communicating ~ 20%
  • SAH cardiacsupportive for Takotsubo (often resolves) + neurogenic pulmonary edema (PEEP, diuretics)
  • CAAAVOID anticoagulation if possible (high rebleeding risk); antiplatelet case-by-case

378.4.3 🎯 盧醫垫的考前提醒

  1. ICH location → etiology: deep (basal ganglia, thalamus, pons, cerebellum) = hypertensive vs lobar (frontal, parietal, occipital, temporal) = CAA (elderly, Aβ deposition, recurrent, microbleeds on SWI) vs other (AVM, tumor, drug, anticoagulation)
  2. Cerebellar ICH > 3 cm or deteriorating → posterior fossa decompression (LIFE-SAVING) — emergency neurosurgery indication
  3. ICH BP management: INTERACT-3 (2023) bundled care + target SBP 140 mmHg lowered mortality + disability; ATACH-2 (intensive ≀ 140 vs 140-180) no mortality diff but more renal AEs
  4. Anticoagulation reversal in ICH: warfarin → 4-factor PCC + vitamin K + dabigatran → idarucizumab + apixaban/rivaroxaban → andexanet alfa (ANNEXA-I 2023, controversial — ↓ hematoma expansion but more thrombotic events) + DO NOT routinely transfuse platelets for antiplatelet-related ICH (PATCH 2016 negative)
  5. ENRICH (NEJM 2024) practice-changing: minimally invasive evacuation for lobar ICH improved outcomes; STICH-I/II routine evacuation negative for supratentorial
  6. SAH presentation: “WORST HEADACHE OF LIFE” thunderclap < 1 min + may follow exertion + LOC ~ 50% + meningismus (delayed) + sentinel headache (warning bleed days-weeks before — easily missed!); CT head sensitive first 6 hr (~ 100%) → LP if CT negative (xanthochromia, most reliable 12 hr-2 weeks)
  7. SAH aneurysm management: coiling > clipping (ISAT trial outcomes) within 24-72 hr; clipping for complex/large/giant/MCA bifurcation/young; pipeline flow diverters select unruptured; anterior communicating most common (~ 30%) + posterior communicating ~ 25% (can compress CN III with pupil involvement — distinguish from diabetic CN III pupil-sparing)
  8. Nimodipine in SAH: 60 mg PO q4h × 21 days — reduces poor outcomes from delayed cerebral ischemia; hold/halve if BP drops
  9. Vasospasm in SAH (peak day 4-14): TCD monitoring + euvolemia + induced HTN if symptomatic (NOT triple-H anymore — older paradigm) + endovascular intra-arterial verapamil/milrinone + balloon angioplasty refractory
  10. SAH complications memorize: hyponatremia from cerebral salt wasting (CSW > SIADH in SAH — hypovolemic, treat with salt + fluid NOT restriction) + cardiac (Takotsubo + neurogenic pulmonary edema + arrhythmias) + hydrocephalus (~ 20% chronic need VP shunt) + rebleeding (before securing) + seizures + DVT/PE; screening 1st-degree relatives + SAH (especially 2+ affected) + ADPKD with FHx → MRA