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Intracranial Bleeding

Case
A 59 year old female who came in for left
sided weakness

Ictus 0550H

Patient was noted to be lying on her left


side with noted slurring of speech. No
fever, vomiting, chest pain ,incontinence,
trauma or loss of consciousness noted
Antecedents
Patient is a known hypertensive and
diabetes exact onset of the condition
is unknown and poorly compliant
with medications.

Non smoker, non alcoholic beverage


drinker, denies illicit drug use.
Approach
History
Time of symptom onset (or time the patient was
last normal)
Initial symptoms and progression of symptoms
Vascular risk factors(Hypertension, diabetes,
hypercholesterolemia, and smoking)
Medications(Anticoagulants, antiplatelet agents )
Recent trauma or surgery
Liver or hematologic disorders
Neurologic Examination in
the ER
Traditional neurologic formulation
follows a three-tiered approach: (1) Is
there a lesion of the nervous system?
(2) Where is the lesion? and (3) What
is the lesion?
ORGANIZATIONAL
FRAMEWORK
1. Mental status testing
2. Higher cerebral functions
3. Cranial nerves
4. Sensory examination
5. Motor system
6. Reflexes
7. Cerebellar testing
8. Gait and station
ORGANIZATIONAL
FRAMEWORK
Higher Cerebral
Mental status testing Functions

Is the patient is Speech and Language


awake, alert, and
Primary sensory
conversant?
modalities (sharp,
Thought content,
light touch, etc.)
attention and memory
Spatial
assessment
ORGANIZATIONAL
FRAMEWORK
3. Cranial nerves
4. Sensory examination
5. Motor system
6. Reflexes
7. Cerebellar testing
8. Gait and station
Differential Diagnosis
Ischemic stroke
Intracranial hemorrhage
Subarachnoid hemorrhage
Drug toxicity
Ischemic stroke
Encephalitis
Intracranial hypotension
Venous thrombosis
Metabolic derangements
Work Up
CT Scan of the head

(CT is optimal for demonstrating


hemorrhage extension into the ventricles,
whereas MRI is superior for demonstrating
underlying structural lesions.)
Work Up
CT angiography and contrast-enhanced CT may be
considered to help identify patients at risk for
hematoma expansion

CT angiography, CT venography, contrast-enhanced


CT, contrast-enhanced MRI, magnetic resonance
angiography, and magnetic resonance venography
can be useful to evaluate for underlying
structural lesions, including vascular
malformations and tumors when there is
clinical or radiological suspicion
Management
Attention to the patient's airway,
monitoring of neurologic status,
Management of hyperthermia with
antipyretics
Administration of antiepileptic
medications if seizures occur
Aggressive management of hyperglycemia
Blood pressure management
Reversal of coagulopathy if present.
Management
Coagulopathy should be reversed. If the coagulopathy is
related to heparin use, protamine should be administered at
approximately 1 milligram per 100 units of heparin, adjusted
based on the time since the heparin was last given.
For patients taking warfarin, reversal should be done no
matter what the international normalized ratio. Several
options exist for reversing warfarin-induced coagulopathy.
Vitamin Kn can be administered IV, SC, or PO but takes
several hours to be effective. Fresh frozen plasma has a
faster onset of effects but contains variable amounts of
clotting factors and may result in the infusion of a large
volume of fluid. Type AB fresh frozen plasma can be given
without typing and cross-match of blood when delays in
preparation and administration must be minimized.
Management
Management of elevated intracranial
pressure (ICP) should include raising the
head of the bed 30 degrees and providing
appropriate analgesia and sedation. If
more aggressive reduction of ICP is
requiredsuch as administration of
osmotic diuretics or intubation with
Neuromuscular blockade and mild
hyperventilationinvasive ICP monitoring
is generally indicated.
Management
Disposition and Follow Up
All patients diagnosed with ICH should
be admitted to an intensive care unit in
consultation with a neurosurgeon.

A higher GCS score is associated with a


better outcome. Factors that predict a
worse outcome are increasing age,
diabetes, and previous anticoagulation
therapy.
Prevention
Prevention of ICH: Summary and
Recommendations
Treatment of hypertension is strongly recommended as
the most effective means to decrease morbidity and
mortality due to ICH
Careful control of the anticoagulation level in patients
prescribed warfarin decreases risk of subsequent ICH
Careful selection of patients for thrombolytic treatment
for acute myocardial infarction and acute ischemic stroke
should result in a decline in ICH rates .
Increased consumption of fruits and vegetables and
avoidance of heavy alcohol and use of sympathomimetic
drugs may decrease risk of ICH.