what can we do in hemorrhagic stroke · what can we do in ! hemorrhagic stroke! assistant professor...
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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
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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
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• 40-60 y!
• HT!
• Common locations!
• No other abnormal CT findings: calcification, enhancement, mass, SAH!
Spontaneous ICH!
Secondary ICH
Lt MCA aneurysm!
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Traumatic CCF!
Aggressive !dural CCF!
MCA !aneurysm!
Basal gg!AVM!
Cerebral aneurysms!
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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.!
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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 !
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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!
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• 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!
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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 !
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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 !
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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 !
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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. !
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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 !
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Left condylar dural AVF with cortical venous reflux !
Clinical presentations depend on !!
• location of the shunts !• type of venous drainage !• flow characteristics !
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• 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 !
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56-year-old female presented with sudden coma and uncal herniation, no history of head injury !
Angiography after right wide craniectomy !
Brain Arteriovenous Malformations!
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• 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
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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!
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Radiosurgery!
Rt.Parietal AVM!
Lateral!AP!
AVM embolization!