what can we do in hemorrhagic stroke · what can we do in ! hemorrhagic stroke! assistant professor...

15/5/19

1

What can we do in !Hemorrhagic Stroke!

Assistant Professor Inthira Khampalikit, MD!Division of Neurosurgery, Department of Surgery!

Faculty of Medicine Siriraj Hospital, Mahidol University !

Ruptured cerebral aneurysm

Ruptured AVM

Spontaneous ICH

Chronic Hypertensive Encephalopathy

Multiple Cavernomas

Cerebral Amyloid Angiopathy

15/5/19

2

Spontaneous ICH!!

Common locations: !Striatocapsular (Basal ganglion) 50%, !

Thalamus 15%, Pons 10-15%, Cerebellum 10%, !

Lobar 10-20%!

Spontaneous ICH!

80%

10% 10%

>> Craniotomy with clot removal

Treatment

15/5/19

3

•  40-60 y!

•  HT!

•  Common locations!

•  No other abnormal CT findings: calcification, enhancement, mass, SAH!

Spontaneous ICH!

Secondary ICH

Lt MCA aneurysm!

15/5/19

4

Traumatic CCF!

Aggressive !dural CCF!

MCA !aneurysm!

Basal gg!AVM!

Cerebral aneurysms!

15/5/19

5

Ruptured cerebral aneurysm with SAH!!

•  Prevalence: 10-28 pt / 100,000 / yr !

•  Age: peak age 55-60 yr old !

•  Course: 10-15% die before reaching hospital !

30% die within 48 hrs !

30 day mortality rate = 46% !

•  1/ 3 of survivors = moderate to severe deficit !

•  1/ 3 of survivors = good result!

•  Very old age = poor prognosis!

•  Outcome is markedly improving!

Sequelae after a cerebral aneurysm ruptured!

•  Re-bleeding!

•  Cerebral vasospasm !

•  Hydrocephalus!

•  Cardiopulmonary complications!

•  Metabolic abnormalities!

•  Within 24 h of aneurysmal SAH, 5% of cases will show no evidence of hemorrhage on CT scan!

•  SAH is visible only 50% by 1 week, 30% after 2 weeks, and 0% after 3 weeks !

Neuroradiology 1982;23:153-156.!

•  CSF xanthochromia is present in all patients up to 2 weeks post SAH and is still present in 70% of patients at 3 weeks. !

J Neurol 1989;52:826-828.!

15/5/19

6

Genetic abnormalities

Hypertension

Hemodynamic stressAtherosclerosis

SmokingAging

Aneurysm

Inflammation/Infection

Trauma

Infectious aneurysms!

42-year-old male underlying ASD !

!

post ASD closure 1 day, !

he developed alteration of consciousness !

15/5/19

7

HIV infection!

HIV-associated intracranial vasculopathy !

•  These patients tend to have CD4 counts below 200 and high HIV viral loads.!

•  Radiographic findings include characteristic diffuse fusiform aneurysms often with hemorrhage or infarct. !

•  Etiology remains unclear!

The Journal of Rheumatology 2010; 37:2 !

Treatment options !

•  Craniotomy with aneurysm clipping!

15/5/19

8

•  Endovascular treatment !•  Aneurysm coiling!

Treatment options !

A B

Aneurysm

Microcatheter

Coil

Occluded aneurysm

C D

•  Vasculitis!

•  Trauma!

•  Atypical PRES!

•  Reversible cerebral vasoconstriction syndrome!

•  Infectious aneurysm!

•  Coagulopathy & thrombocytopenia!

•  Venous sinus & cortical v thrombosis !

•  Aggressive DAVF!

•  Micro AVM!

Cortical SAH!

15/5/19

9

A 38-year-old pregnant woman presented with seizure post partum !

Reversible cerebral vasoconstriction syndrome !

•  Acute and severe headache with or without focal deficits or seizures !

•  Uniphasic course without new symptoms more than 1 month after clinical onset !

•  Segmental vasoconstriction of cerebral arteries shown by indirect or direct angiography !

•  No evidence of aneurysmal SAH !

•  Normal or near-normal CSF (protein <100 mg/dL, <15 WBC/μL) !

•  Complete or substantial normalisation of arteries shown by F/U indirect or direct angiography within 12 wks of clinical onset !!

Lancet Neurol 2012; 11: 906–17 !

15/5/19

10

Precipitants of RCVS!•  Post partum !

•  Vasoactive drugs : Illegal drugs, Antidepressants, α-sympathomimetics, Triptans, Ginseng !

•  Catecholamine-secreting tumors : Phaeochromocytoma, bronchial carcinoid tumor, glomus tumors !

•  Immunosuppressants or blood products : IV Ig, RBC transfusion,109 interferon α!

•  Miscellaneous : Hypercalcemia, porphyria, head trauma, phenytoin intoxication !

Lancet Neurol 2012; 11: 906–17 !

Aneurysm???!

Right dural CCF with cortical venous reflux !

15/5/19

11

Dural arteriovenous fistula!

Cranial dural AVF

Shunts: Dural sleeve

Supply:

•  Transosseous branches of scalp arteries

• Dural arteries

Draining:

•  Dural venous sinuses

• Cortical veins

Pathogenesis!•  Idiopathic!

•  Venous thrombosis!

•  Trauma!

•  Tumor!

•  Previous neurological surgery !

•  Meningitis !

•  Sinus infection !

15/5/19

12

Benigntype

Aggressivetype

Aggressive DAVF!

•  Annual hemorrhage rate of 8.1%!•  Progressive dementia syndrome rate of 6.9% !•  Annual mortality rate was 10% !

Stroke. 2002;33:1233–1236.!!

Annual risk for hemorrhagic or non-hemorrhagic neurological deficits of 15%

Aggressive DAVF!

•  DAVF patients presenting with hemorrhage, 35% of them had early rebleeding !

•  mean time ∼ 20 days!

J Neurosurg. 1999;90:78–84. !

15/5/19

13

41-year-old man presented with pulsatile tinnitus for 5 months !

Aggressive!

or!

Benign!Benign!

39-year-old man presented with sudden severe occipital

headache for 1 day !

15/5/19

14

Left condylar dural AVF with cortical venous reflux !

Clinical presentations depend on !!

•  location of the shunts !•  type of venous drainage !•  flow characteristics !

15/5/19

15

•  Tinnitus!•  Headache !•  Ataxia !•  Parkinsonism!•  Locked-in syndrome !•  Myelopathy!•  Cognitive dysfunction !•  Cranial neuropathy !•  NPH-like symptoms

(Hydrocephalus)!•  ICH,SDH,SAH,IVH!•  Seizure!•  Chemosis, proptosis!•  Secondary glaucoma!•  Prominent scalp

arteries !

Clinical presentations of DAVF!

46-year-old female with pseudotumor cerebri !

15/5/19

16

56-year-old female presented with sudden coma and uncal herniation, no history of head injury !

Angiography after right wide craniectomy !

Brain Arteriovenous Malformations!

15/5/19

17

•  A 39-year-old male, U/D HT, gout !

•  PI: 3 mo PTA- right hemiparesis, facial palsy and difficulty speaking (onset 15/09/2016)!

– PE: motor power grade 0 right side , grade V left side, aphasia!

Ruptured right temporal AVM

15/5/19

18

Clinical manifestations!

•  Intracerebral hemorrhage!

•  Seizure!

•  Neurological deficit !

•  Incidental finding!

•  Annual hemorrhage risk for unruptured AVM is 2-4%.

•  Hemorrhage risk increase in previously ruptured AVM especially in the first year.

Clinical manifestations!

Treatment options !

•  Craniotomy with AVM resection- small (<3 cm), superficial non-eloquent location !

•  Radiosurgery- small (<3 cm), deep location!

•  Embolization!

15/5/19

19

Radiosurgery!

Rt.Parietal AVM!

Lateral!AP!

AVM embolization!