{ Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg, M.D.

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{ Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg , M.D.

Transcript of { Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg, M.D.

Page 1: { Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg, M.D.

{

Intracranial Hemorrhage

January 2014

Prianka ChilukuriCameron, M.D., Sclamberg , M.D.

Page 2: { Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, 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

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Labs: elevated PT, low fibrinogen !? DIC

ROS: No headache, vision changes, fever Platelet transfusions Initial exam – NL except for bruises and

petichiae

HPI

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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

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Leukemic involvement of brain Hemorrhagic stroke Ischemic stroke Aneurism Infection Sepsis Vasculitis

Differential Diagnoses:

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CT Head w/ IV contrast CT Head w/out IV contrast MRI brain CT angiogram MR angiogram Ultrasound head

Diagnostic Imaging Menu:

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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

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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

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Normal CT – Sagittal plane

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PT’s CT – Sagittal plane Accession#: 5483133

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PT’s CT – Sagittal planeAccession#: 5483133

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PT’s CT – Coronal planeAccession#: 5483133

Page 13: { Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg, M.D.

Normal CT – Axial plane

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PT’s CT – Axial planeAccession#: 5483133

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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

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PT’s CT – Sagittal planeAccession#: 5484184

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Previous CT – Sagittal plane Accession#:

5484184

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PT’s CT – Coronal planeAccession#: 5484184

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Previous CT – Coronal plane

MRN: 6623472

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PT’s CT – Axial planeAccession#: 5484184

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Previous CT – Axial planeAccession#: 5484184

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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

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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

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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

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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