{ Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg, M.D.
-
Upload
vivien-stewart -
Category
Documents
-
view
218 -
download
0
Transcript of { Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg, M.D.
{
Intracranial Hemorrhage
January 2014
Prianka ChilukuriCameron, M.D., Sclamberg , M.D.
50 year old male, no sig PMH Respiratory symptoms, fatigue x 2 weeks Bleeding lesions on skin, petichiae, gums
bleeding ED: thrombocytopenia, peripheral smear
(45% blasts, +Auer rods) Bone marrow bx: APML
Transferred here
HPI
Labs: elevated PT, low fibrinogen !? DIC
ROS: No headache, vision changes, fever Platelet transfusions Initial exam – NL except for bruises and
petichiae
HPI
Headache 3/10, vitals stable Spiked fever, low grade headaches + N&V Team held off on CT Later on, N&V worsened + new onset diarrhea
with blood in stool, bradycardia 40-60s Decreased respiratory status and mental
status CT head ordered, but upon transport
worsening mental status. Exam – Following commands, PERRLA,
extremity movement intact SBP: 180s
During stay
Leukemic involvement of brain Hemorrhagic stroke Ischemic stroke Aneurism Infection Sepsis Vasculitis
Differential Diagnoses:
CT Head w/ IV contrast CT Head w/out IV contrast MRI brain CT angiogram MR angiogram Ultrasound head
Diagnostic Imaging Menu:
Rationale – Widespread access Speed of acquisition Highly sensitive for detecting hemorrhage
in acute setting Evident almost immediately Able to see extension of a hematoma,
surrounding edema, and herniation MRI – T2 sensitive pulse sequences; highly
sensitive but time consuming; better at detecting underlying cause of bleed
CT head w/out IV contrast
New focal neurological defect, fixed or worsening <3 hours:
CT head w/out IV contrast: 9 MRI w/out contrast: 8 MRI w/ and w/out contrast: 8 MRA w/out or MRA w/ and w/out: 8
Same for CTA 3-24 hours:
MRI head w/out contrast: 8 CT w/out contrast: 8
>24 hours: MRI head w/out contrast: 8
ACR Appropriateness Criteria
Normal CT – Sagittal plane
PT’s CT – Sagittal plane Accession#: 5483133
PT’s CT – Sagittal planeAccession#: 5483133
PT’s CT – Coronal planeAccession#: 5483133
Normal CT – Axial plane
PT’s CT – Axial planeAccession#: 5483133
Patient transferred to NSICU Neuro exam temporarily improved with
mannitol Multiple units of platelets and FFP Followed by acute decline in neurological
exam Physical exam – dilated, unreacting R
pupil + extensor posturing, pt hypeventilating and active bleeding from central line
Stat CT ordered
Clinical course
PT’s CT – Sagittal planeAccession#: 5484184
Previous CT – Sagittal plane Accession#:
5484184
PT’s CT – Coronal planeAccession#: 5484184
Previous CT – Coronal plane
MRN: 6623472
PT’s CT – Axial planeAccession#: 5484184
Previous CT – Axial planeAccession#: 5484184
Includes both medical and surgical options Patient should be cared for in an ICU setting If have fever, should be treated with
antipyretic Maintenance fluids with normal saline;
hypotonic fluids can exacerbate edema and ICP.
Reverse any anticoagulation Control BP Elevate bed to 30 degrees to dec ICP Sedation to dec ICP [propofol] Mannitol Surgery
Treatment
Neurosurg was consulted, surgery was not indicated
Mannitol did not help improve mental status,
Patient remained intubated, sedated, and unresponsive
Palliative care came on board, family made decision to withdraw care
Clinical course
Hematoma growth – particularly within first 24 hours; independent predictor of mortality and poor outcome [10% growth, 5% death]
Intraventricular and subarachnoid extension – Also an independent predictor
Prognosis
Rodriguez-Luna D, Rubiera M, Ribo M, et al. Ultraearly hematoma growth predicts poor outcome after acute intracerebral hemorrhage. Neurology 2011; 77:1599.
Hallevi H, Albright KC, Aronowski J, et al. Intraventricular hemorrhage: Anatomic relationships and clinical implications. Neurology 2008; 70:848
Kidwell CS, Chalela JA, Saver JL, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA 2004; 292:1823.
Kidwell CS, Wintermark M. Imaging of intracranial haemorrhage. Lancet Neurol 2008; 7:256.
References