Download - Micro bleed

Transcript
Page 1: Micro bleed

Dr.Bipin Bhimani M.D.,D.M.

Consultant Neurophysician

Well care Hospital

Rajkot

Page 2: Micro bleed

Case :• M / 44 yrs• Sudden onset of Weakness/ Clumsiness/ giving away of both LLS• About to fall but was supported• Lasted for few minutes (2-5 minutes)• ? Sensory ( numbness)• Recovered totally.

Page 3: Micro bleed

• RHD/MS/BMV done 1 month ago• No AF/ clot/ LA-near ok / no smoke• Past h/o ? Cerebellar Stroke 2 yrs back (Admitted/No reports available) • Ecospirin OD/150mg

Page 4: Micro bleed
Page 5: Micro bleed
Page 6: Micro bleed
Page 7: Micro bleed
Page 8: Micro bleed
Page 9: Micro bleed
Page 10: Micro bleed
Page 11: Micro bleed
Page 12: Micro bleed
Page 13: Micro bleed

• ? Spinal cord TIA• ? Cerebral TIA• ? Symptomatic microbleed

Page 14: Micro bleed

• Normal course: admission, observation Repeat ECHO heparinisation anticoagulants• Any change in view of multiple micro bleeds ?

Page 15: Micro bleed

Affects many therapeutical decisions

• Aspirin• Clopidogrel• Asp +Dypiridamole • Asp+ Clop• Asp+Clop+cilastazol• Anticoagulants /Heparin• tPA

Page 16: Micro bleed

CMBs/BMBs

• Mid 1990s • Focal hemosiderin,DOHb,Ferittin

(macrophage)of previous hemorrhage• ( perivascular)• < 5 mm round (actually smaller)• Usually BG/ SC , in CAA cortical • Also cerelellum, brain stem • Persists for many years

Page 17: Micro bleed

• Fibrohyalinosis or CAA, <200 micrometer vessel rupture

• Gradient Echo ( focal areas of signal loss) T2• Susptibility Weighted –better

Page 18: Micro bleed

Cortical (CAA) Vs SC (HT)

Page 19: Micro bleed

Criteria of CMBs

• 1 Black lesions on T2*-weighted MRI• 2 Round or ovoid lesions (rather than linear)• 3 Blooming effect on T2*-weighted MRI*• 4 Devoid of signal hyperintensity on T1- or T2• 5 At least half the lesion surrounded by brain

parenchyma • 6 Distinct from other potential mimics such as iron

or calcium deposits • 7 Clinical history excluding traumatic DAI

Page 20: Micro bleed

CMBs are seen in

• Healthy adults • Healthy elderly• Lacunar and other ischemic strokes• ICH• Cerebral amyloid angiopathy• CADASIL • Some genetic collagen disease• Alz disease• Moyamoya disease

Page 21: Micro bleed

Associations

• Older age• Asian • Male • HT ?DM • Smoking• White matter disease• ICH• Lacunes/Ischemic strokes • Low cholestrol (?)

Page 22: Micro bleed

• 53 yrs ----3.1%• 60 yrs ----6%• HT – • Male more • Ischemic -34%• Hemorrhagic-60%• Alz-20%• Much more in recurrent strokes

Page 23: Micro bleed

Benign or pathological • Small vessel disease• Further Stroke burden • ( ischemic/hemorrhagic)• More bleed size• Increase Hemorrhagic transformation of infarcts • Executive dysfunction• Cognitive decline • Further future events in CAA• New bleed accumulates over time

Page 24: Micro bleed

CMB detection

• Tesla (field strength)• Echo time • Flip angle • Slice thickness

Page 25: Micro bleed

Scores:

• MARS- Microbleed Anatomical Rating Scale

• BOMBs- Brain Observer Micro Bleed Scale

Page 26: Micro bleed

DDs

• Micro hemorrhagic mets• Calcium /iron ( symmetrical )• Cerebral Cavernoma (rare, hereditary)• Capillary telangiectasias • Leptomeningial hemosiderosis• Vascular flow voids (can trace vessel course)• Diffuse Axonal injury ( trauma )

Page 27: Micro bleed

Prevention

• Anti HT ( peri/Indapa)• Cessation of smoking

• Avoid anticoagulants

Page 28: Micro bleed
Page 29: Micro bleed

Is CMBs symptomatic?

• Acute –usually no symptoms ,occ seizure by irritation of brain parencyma , occ focal symptoms

• Chronic- executive dysfunction

• Not an innocent bystander

Page 30: Micro bleed

Suspected acute symptomatic CMBs

Page 31: Micro bleed

paradox

• In some recurrent “TIA” like cases, incressing dose of antiplatelets or adding new one exacerbates problem…while reducing antiplatelets or anti-convulsants solve the problems!

Page 32: Micro bleed

CMBs and anti-thrombotics

• Should not be withheld

• Do not withheld aspirin

• Avoid double esp if multiple/Lobar CMBs

Page 33: Micro bleed

CMBs and anticoagulants

• Avoid anticoagulation or double anti platelets in CAA ( multiple, lobar)

Page 34: Micro bleed

Warfarin ICH and CMBs

Page 35: Micro bleed

CMBs and tPA

• MR is usually not done• Go ahead• Minor Contraindication• Statistically insignificant trend of increase ICH • Symptomatic ICH rare

Page 36: Micro bleed

Thank you