The document discusses the anatomy and blood supply of the brain, causes and clinical presentation of intracerebral hemorrhage, diagnostic evaluation using CT and MRI, management including treatment of elevated intracranial pressure and coagulopathy, and prognosis. Key points include the anterior and posterior circulations supplying the brain, common sites of hemorrhage being the putamen and lobar regions, clinical signs varying based on location of bleed, and treatment focusing on airway control, ICP monitoring, hyperosmolar therapy, and reversing anticoagulation when applicable.
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Subarachnoid hemorrhage a major complication ,this presentation can help you understand the disease, the signs & symptoms and give you the diagnostic feature ,I hope you well enjoy studying it ... Good luck :)
Is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.
It can occur
in the carotid
artery of the
neck as well as
other arteries.
When an artery is acutely occluded by thrombus or embolus, the area of the CNS supplied by it will undergo infarction if there is no adequate collateral blood supply.
Surrounding a central necrotic zone, an ‘ischemic penumbra’ remains viable for a time, i.e. it may recover function if blood flow is restored.
CNS ischemia may be accompanied by swelling for two reasons:
● cytotoxic oedema – accumulation of water in damaged glial cells and neurones,
● vasogenic oedema – extracellular fluid accumulation as a result of breakdown of the blood–brain barrier.
In the brain, this swelling may be sufficient to produce clinical deterioration in the days following a major stroke, as a result of a rise in intracranial pressure and compression of adjacent structures.
Subarachnoid hemorrhage a major complication ,this presentation can help you understand the disease, the signs & symptoms and give you the diagnostic feature ,I hope you well enjoy studying it ... Good luck :)
Is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.
It can occur
in the carotid
artery of the
neck as well as
other arteries.
When an artery is acutely occluded by thrombus or embolus, the area of the CNS supplied by it will undergo infarction if there is no adequate collateral blood supply.
Surrounding a central necrotic zone, an ‘ischemic penumbra’ remains viable for a time, i.e. it may recover function if blood flow is restored.
CNS ischemia may be accompanied by swelling for two reasons:
● cytotoxic oedema – accumulation of water in damaged glial cells and neurones,
● vasogenic oedema – extracellular fluid accumulation as a result of breakdown of the blood–brain barrier.
In the brain, this swelling may be sufficient to produce clinical deterioration in the days following a major stroke, as a result of a rise in intracranial pressure and compression of adjacent structures.
intracranial hemorrhage- by KEMISA HASSEN ZAINABU IIHS_jinjaUGANDA (2).pptxHASSENZAINABUKEMISA
By the end of this we shall be able to know the following
definition.of intracranial hemorriage
Classification of intracranial hemorriage
Types of intracranial hemorriage.
Causes of intracranial hemorriage.
Signs and symptoms of intracranial hemorriage
Investigations specific management.
Complication.
Ongoing nursing care.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
7. M1 segment – lenticulostriate branches
most parts of internal capsule
hemiplegia of UMN type
Putamen
Outer globus pallidus
Body, upper and lateral head of
caudate nucleus
charcot’s artery of cerebral hge
- hemiplegia with deep coma
8. Superior division
motor cortex
sensory cortex
broca’s area
frontal eye field
Inferior division
wernicke’s area
auditory area
optic radiation
9. 2 segments – A1 segment ( pre communal )
A2 segment ( post communal )
10. A1 segment
anterior limb of internal capsule
anterior perforate substance
anterior hypothalamus
amygdala
inferior part of head of caudate
nucleus
` Recurrent artery of Heubner –
faciobrachial monoplegia
11. motor area of leg
sensory area of leg
paracentral lobule
corpus callosum
superior frontal gyrus
ACA
PCA
MCA
12. POSTERIOR CEREBRAL ARTERY
In 75% cases both PCA arises
from the bifurcation of basilar
artery
20% one from ipsilateral ICA
5% both from respective
ipsilateral ICA
Two segments
P1 segment
P2 segment
13. The artery of Percheron – inferomedial and
anterior thalamus and subthalamus
Thalamogeniculate branches
Medial posterior choroidal artery
Lateral posterior choroidal artery
Other areas – middle cerebral peduncle
substantia nigra
red nucleus
medial lemniscus
MLF
14. Lateral part of cerebral peduncle
Medial lemniscus
Tegmentum of midbrain
Superior colliculi
Lateral geniculate body
17. Branches
Pontine
Labyrinthine
Anterior inferior cerebellar
Superior cerebellar
Posterior cerebral
Supplies
base of pons and
superior cerebellum
18.
19.
20.
21.
22. third most frequent cause of stroke,
following cerebral embolism and
thrombotic disease.
23. Vascular malformations
Intracranial tumors
Bleeding disorders, anticoagulant and
fibrinolytic treatment
Cerebral amyloid angiopathy
Granulomatous angiitis of the central nervous
system and other vasculitides, such as
polyarteritis nodosa
Sympathomimetic agents (including
amphetamine and cocaine)
Hemorrhagic infarction
Head trauma
24.
25. the most common sites of a cerebral
hemorrhage are
(1) the putamen and adjacent internal capsule
(2) the central white matter of the temporal,
parietal, or frontal lobes (lobar hemorrhages,
not strictly associated with hypertension);
(3) the thalamus;
(4) one or the other cerebellar hemisphere;
and
(5) the pons.
26. Multiple, nearly simultaneous intracerebral
hemorrhages raise the possibility of
amyloid angiopathy or a bleeding diathesis
27.
28.
29. age <65 years,
female sex,
nonsmoker,
lobar ICH,
Intraventricular extension,
absence of a history of hypertension or
coagulopathy
30.
31. In the first hours and days following the
hemorrhage, varying degrees of edema
evolve around the clot and add to the
mass effect.
Hydrocephalus may occur as a result of
bleeding into the ventricular system or
from compression of the third ventricle.
32. The extravasated blood undergoes a
predictable series of changes. At first fluid,
the collection becomes a clot.
Before the clot forms, red cells settle in the
dependent part of the hematoma and form
a meniscus with the plasma above;
particularly in cases of anticoagulant-
induced hemorrhage. The resultant fluid-
fluid level ("hematocrit effect") .
33. Within a few days, hemoglobin products,
mainly hemosiderin and hematoidin, begin
to appear.
The hemosiderin forms within histiocytes
that have phagocytized red blood cells
(RBCs) and takes the form of ferritin
granules that stain positively for iron.
34. As oxyhemoglobin is liberated from the
RBCs and becomes deoxygenated,
methemoglobin appears. This begins
within a few days and imparts a brownish
hue to the periphery of the clot.
Phagocytosis of red cells begins within 24
h, and hemosiderin is first observed
around the margins of the clot in 5 to 6
days
35. The clot changes color gradually over a few weeks
from dark red to pale red, and the border of
golden-brown hemosiderin widens.
The edema disappears over many days or weeks.
In 2 to 3 months, larger clots are filled with a
chrome-colored thick fluid, which is slowly
absorbed, leaving a smooth-walled cavity or a
yellow-brown scar.
The iron pigment (hematin) becomes dispersed
and studs adjacent astrocytes and neurons and
may persist well beyond the border of the
hemorrhage for years.
36. On CT, fresh blood is visualized as a white
mass as soon as it is shed. The "spot
sign," the appearance of contrast within
the hemorrhage during CT angiography.
After 2 to 3 weeks, the surrounding edema
begins to recede and the density of the
hematoma decreases, first at the
periphery.
37.
38. At one point several weeks after the bleed,
the appearance may transiently simulate a
tumor or abscess.
By :M.RI, either in conventional Tl- or T2-
weighted images, the hemorrhage is not
easily visible in the 2 or 3 days after bleeding,
as oxyhemoglobin is diamagnetic or, at most,
is slightly hypointense, so that only the mass
effect is evident.
MR gradient echo or equivalent sequences
that display areas of magnetic susceptibility
show hemorrhages earlier and detect
remnants of deposited hemosiderin even
years afterward.
39. As deoxyhemoglobin and methemoglobin
form, the hematoma signal becomes bright
on Tl-weighted images and dark on T2.
The hematoma is then subacute and the
dark signal gradually brightens.
Massive refers to hemorrhages several
centimeters in diameter, usually larger than
50 mL; small applies to those 1 to 2 cm in
diameter and less than 20 mL in volume.
40.
41.
42. The hypertensive vascular lesion that
leads to arteriolar rupture in most cases
appears to arise from an arterial wall
altered by the effects of hypertension,
i.e., the change referred to in a preceding
section as segmental lipohyalinosis and
the false aneurysm (microaneurysm)
named for Charcot and Bouchard
43. Acute reactive hypertension
Vomiting
Nuchal rigidity
Seizures usually focal, occur in the first
few days in only 10 percent of cases of
supratentorial hemorrhage.
fundus hypertensive changes in the
arterioles.
44. In putaminal hemorrhage, the eyes are
deviated to the side opposite the paralysis;
in thalamic hemorrhage, ocular abnormality is
downward deviation of the eyes and the
pupils may be unreactive;
in pontine hemorrhage, the eyeballs are fixed
and the pupils are tiny but reactive;
in large cerebellar hemorrhage, the eyes may
be deviated laterally to the side opposite the
lesion and ocular bobbing may occur (as
often cerebellar hemorrhage in awake
patients there are no eye signs).
45. most common syndrome is the one caused
by putaminal hemorrhage with extension to
the adjacent internal capsule.
hemiplegia from interruption of the capsule
is a consistent feature of medium-sized
and large clots.
Vomiting occurs in about half the patients.
Headache is frequent
46. More advanced stages are characterized by
signs of upper brainstem compression ;
bilateral Babinski signs;
irregular or intermittent respiration;
dilated, fixed pupils, first on the side of the
clot; and
decerebrate rigidity.
47. With hemorrhages confined to the anterior
segment of the putamen, the hemiplegia and
hyperreflexia tend to be less severe and to
clear more rapidly. also prominent abulia,
motor impersistence, temporary unilateral
neglect, and with left-sided lesions, nonfluent
aphasia, and dysgraphia.
With small posterior lesions, weakness is also
mild and is attended by sensory loss,
hemianopia, impaired visual pursuit to the
opposite side, Wernicke-type aphasia (left-
sided lesions), and anosognosia (right-sided)
.
48.
49. Those extending laterally and posteriorly
into the internal capsule behave much like
large putaminal hemorrhages.
Those extending medially into the lateral
ventricle give rise to drowsmess, stupor,
and either confusion and underactivity or
restlessness and agitation.
50.
51. severe sensory loss on the entire
contralateral body.
If large or moderate in size, thalamic
hemorrhage also produces a hemiplegia or
hemiparesis by compression or destruction
of the adjacent internal capsule.
The sensory deficit involves all of the
opposite side including the trunk and may
exceed the motor weakness.
52. A fluent aphasia may be present with
lesions of the dominant side
contralateral neglect, with lesions of the
nondominant side.
Thalamic hemorrhage, by virtue of its
extension into the subthalamus and high
midbrain, may also cause a series of
ocular disturbances- pseudoabducens
palsies with one or both eyes turned
asymmetrically inward and slightly
downward, palsies of vertical and lateral
gaze,
53. forced deviation of the eyes downward,
inequality of pupils
absence of light reaction,
skew deviation with the eye ipsilateral to
the hemorrhage assuming a higher
position than the contralateral eye,
ipsilateral ptosis and miosis (Horner
syndrome),
54. Compression of the adjacent third ventricle
leads to enlargement of the lateral
ventricles that may require temporary
drainage.
early hydrocephalus is common
55.
56. deep coma within a few minutes;
total paralysis with bilateral Babinski signs,
decerebrate rigidity,
small (1-mm) pupils that react to light.
Lateral eye movements, evoked by head
turning or caloric testing, are impaired or
absent.
57.
58. loss of consciousness at the onset is unusual.
Repeated vomiting is a prominent feature,
Occipital headache, vertigo, and inability to
sit, stand, or walk.
A mild ipsilateral facial weakness, diminished
corneal reflex, paresis of conjugate lateral
gaze to the side of the hemorrhage, or an
ipsilateral sixth-nerve weakness occur with
larger hemorrhages
59. or extend into the cerebellar peduncle.
Dysarthria and dysphagia may be prominent
in some cases but usually are absent.
infrequent ocular signs :blepharospasm,
involuntary closure of one eye, skew
deviation, "ocular bobbing," and small, often
unequal pupils that continue to react.
Contralateral hemiplegia and ipsilateral facial
weakness occur if there is marked
displacement and compression of the medulla
against the clivus.
60. The plantar reflexes are flexor in the early
stages but extensor later. When these
signs occur, hydrocephalus is usually
found and may require drainage.
cerebellar hemorrhage is the most
amenable to surgical evacuation with good
results.
61. Bleeding in areas specifically in the
subcortical white matter of one of the lobes
of the cerebral hemisphere
not associated strictly with hypertension.
Causes: anticoagulation or thrombolytic
therapy; acquired coagulopathies, cranial
trauma, arteriovenous, trauma, and, in the
elderly, amyloidosis of the cerebral
vessels.
62. Most lobar hemorrhages are spherical or
ovoid, but a few follow the contour of the
subcortical white matter tracts and take the
form of a slit (subcortical slit hemorrhage).
many of these are the result of a bleeding
diathesis, such as thrombocytopenia.
63.
64.
65. The spot sign on CT angiography in relation
to hematoma expansion.
coexisting hydrocephalus, tumor, cerebral
swelling, and displacement of the intracranial
contents are readily appreciated.
MRI is particularly useful for demonstrating
brainstem hemorrhages and residual
hemorrhages, which remain visible long after
they are no longer detectable on the CT (after
4 to 5 weeks).
66. The white cell count in the peripheral blood
may rise transiently to 15,000/mm3, a
higher figure than in thrombosis, but it is
most often normal.
The sedimentation rate may be mildly
elevated in some patients.
Determination of the INR, partial
thromboplastin time, and platelet count is
advisable.
67. A volume of 30 mL or less, calculated by
various methods from the CT predicted a
generally favorable outcome.
68.
69.
70.
71. If the patient has a depressed level of
consciousness and a Glasgow Coma
Scale score of 8 or less, endotracheal
intubation should follow.
This is best performed with the
administration of short-acting IV agents
such as thiopental (1-5 mg/kg) or lidocaine
(1 mg/kg) to block the increases in ICP that
result from tracheal stimulation.
72. the maintenance of adequate ventilation,
selective acute use of controlled
hyperventilation to a Pco2 of 25 to 30 mm Hg,
monitoring of intracranial pressure
tissue-dehydrating agents such as mannitol
(0.25-1 g/kg), (osmolality kept at 295 to 305
mOsm/L and Na at 145 to 150 mEq).
limit intravenous infusions to normal saline.
73. Although dexamethasone is frequently
given with the purpose of decreasing
intracranial hypertension by reducing
cerebral edema, its use is not supported
by data
74. ICH due to heparin anticoagulation should
be treated with protamine sulfate, 1 mg per
100 units of heparin estimated in plasma,
those on warfarin should receive 5 to 25
mg of IV vitamin K1 and, most important,
fresh frozen plasma (10-20 mL/kg) or
prothrombin complex concentrate.
75. FEIBA (factor VIII inhibitor bypassing activity)
or rFVIIa may be better for the direct thrombin
inhibitor dabigatran, whereas other PCCs
may be better for the factor Xa inhibitors
rivaroxaban and apixaban.
Activated charcoal can be used if the most
recent dose of dabigatran, apixaban, or
rivaroxaban was taken within the previous
couple of hours.
Hemodialysis has been noted as an option for
dabigatran, but less so for rivaroxaban or
apixaban because these are more highly
protein bound
76. PCCs are plasma-derived factor
concentrates originally developed to treat
factor IX deficiency (hemophilia B).
Instances of ICH after thrombolytic therapy
are best treated with 4 to 6 units of
cryoprecipitate or fresh frozen plasma, as
well as single-donor platelets.
77. Although rFVIIa can limit the extent of
hematoma expansion in noncoagulopathic
ICH patients, there is an increase in
thromboembolic risk with rFVIIa and no
clear clinical benefit in unselected patients.
Thus, rFVIIa is not recommended
78. intermittent pneumatic compression for prevention
of venous thromboembolism beginning the day of
hospital admission
Graduated compression stockings are not
beneficial to reduce DVT or improve outcome)
After documentation of cessation of bleeding,
lowdose subcutaneous low-molecular-weight
heparin or unfractionated heparin may be
considered for prevention of venous
thromboembolism in patients with lack of mobility
after 1 to 4 days from onset
79. Systemic anticoagulation or IVC filter
placement is probably indicated in ICH
patients with symptomatic DVT or PE
80. Rapid reduction of moderately elevated blood
pressure (between 140 and 160 mm Hg systolic),
is not recommended,
sustained mean blood pressures of greater than
110 mm Hg (generally above 160 mm Hg systolic)
use of beta-blocking drugs (esmolol, labetalol) or
angiotensin-converting enzyme (ACE) inhibitors is
recommended.
The major calcium channel blocking drugs are
used less often for this purpose because of reports
of adverse effects on intracranial pressure,
although this information derives mainly from
patients with brain tumors
81. Pharmacological correction of severe hypertension (blood pressure
>180/105 mm Hg) is recommended in the acute phases of ICH,
the goal being maintenance of normal cerebral perfusion pressure levels on
the order of 60 to 70 mm Hg, aiming at a blood pressure of 160/90 mm Hg
The antihypertensive agent of choice in this setting is the IV beta- and alpha-
blocking agent, labetalol, often used in combination with loop diuretics.
The use of the IV calcium channel blocker, nicardipine, is an equally
appropriate choice in this setting in view of its lack of cerebral vasodilatory
effect. These IV agents have the advantage of being rapidly effective and
easy to titrate.
82. For ICH patients presenting with SBP
between 150 and 220 mm Hg and without
contraindication to acute BP treatment,
acute lowering of SBP to 140 mm Hg is
safe and can be effective for improving
functional outcome.
For ICH patients presenting with SBP
>220 mm Hg, it may be reasonable to
consider aggressive reduction of BP with a
continuous intravenous infusion and
frequent BP monitoring
83. Seizures, a feature of the lobar rather than
deep ganglionic varieties of ICH, typically
occur at onset.
In patients who did not have early
seizures, there is a negligible risk of late
epilepsy.
routine prophylactic use of anticonvulsants
in patients with ICH is not justified.
84. A direct surgical approach is considered
frequently in patients with superficial (lobar)
hematomas of the cerebral hemispheres or
with cerebellar hemorrhage,
patients with deep hemorrhages (caudate,
thalamic, pontine, mesencephalic, and
medullary in location) are rarely surgical
candidates.
Putaminal hemorrhage occupies an
intermediate position and is most
controversial.
85. In addition to direct evacuation of a
hematoma, there is the option of ventricular
drainage for the relief of hydrocephalus and
increased ICP in cases of cerebellar,
thalamic, and caudate ICH.
In cerebellar hemorrhage, massive
hydrocephalus can be a major cause of
clinical deterioration, and ventriculostomy
may provide dramatic improvement
86. the surgical evacuation of cerebellar
hematomas is a generally accepted treatment
and is a more urgent matter because of the
proximity of the mass to the brainstem and
the risk of abrupt progression to coma and
respiratory failure.
Also, hydrocephalus from compression of the
fourth ventricle more often complicates the
clinical picture and further raises intracranial
pressure
87. cerebellar hematoma less than 2 cm in
diameter generally not requiring surgery.
Hematomas that are 4 Cm or more in
largest diameter, especially if located in the
vermis, pose the greatest risk,
recommended evacuation of lesions of this
size no matter what the clinical status of
the patient.
88. Lifestyle modifications, including
avoidance of alcohol use greater than 2
drinks per day, tobacco use, and illicit drug
use, as well as treatment of obstructive
sleep apnea, are probably beneficial.
There are insufficient data to recommend
restrictions on the use of statins in ICH
patients
89. Avoidance of long-term anticoagulation
with warfarin as a treatment for
nonvalvular atrial fibrillation is probably
recommended after warfarin-associated
spontaneous lobar ICH because of the
relatively high risk of recurrence
Anticoagulation after nonlobar ICH and
antiplatelet monotherapy after any ICH
might be considered, particularly when
there are strong indications for these
agents
90. The optimal timing to resume oral
anticoagulation after anticoagulant-related
ICH is uncertain.
Avoidance of oral anticoagulation for at
least 4 weeks, in patients without
mechanical heart valves, might decrease
the risk of ICH recurrence
If indicated, aspirin monotherapy can
probably be restarted in the days after ICH