{ Intracranial Hemorrhage January 2014 Prianka Chilukuri Cameron, M.D., Sclamberg, M.D.

 50 year old male, no sig PMH  Respiratory symptoms, fatigue x 2 weeks  Bleeding lesions on skin, petichiae, gums bleeding  ED: thrombocytopenia, peripheral smear (45% blasts, +Auer rods)  Bone marrow bx: APML  Transferred here HPI

 Labs: elevated PT, low fibrinogen  !? DIC  ROS: No headache, vision changes, fever  Platelet transfusions  Initial exam – NL except for bruises and petichiae HPI

 Headache 3/10, vitals stable  Spiked fever, low grade headaches + N&V  Team held off on CT  Later on, N&V worsened + new onset diarrhea with blood in stool, bradycardia 40-60s  Decreased respiratory status and mental status  CT head ordered, but upon transport worsening mental status.  Exam – Following commands, PERRLA, extremity movement intact  SBP: 180s During stay

 Leukemic involvement of brain  Hemorrhagic stroke  Ischemic stroke  Aneurism  Infection  Sepsis  Vasculitis Differential Diagnoses:

 CT Head w/ IV contrast  CT Head w/out IV contrast  MRI brain  CT angiogram  MR angiogram  Ultrasound head Diagnostic Imaging Menu:

 Rationale –  Widespread access  Speed of acquisition  Highly sensitive for detecting hemorrhage in acute setting  Evident almost immediately  Able to see extension of a hematoma, surrounding edema, and herniation  MRI – T2 sensitive pulse sequences; highly sensitive but time consuming; better at detecting underlying cause of bleed CT head w/out IV contrast

 New focal neurological defect, fixed or worsening <3 hours:  CT head w/out IV contrast: 9  MRI w/out contrast: 8  MRI w/ and w/out contrast: 8  MRA w/out or MRA w/ and w/out: 8  Same for CTA  3-24 hours:  MRI head w/out contrast: 8  CT w/out contrast: 8  >24 hours:  MRI head w/out contrast: 8 ACR Appropriateness Criteria

Normal CT – Sagittal plane

PT’s CT – Sagittal plane Accession#:

PT’s CT – Sagittal plane Accession#:

PT’s CT – Coronal plane Accession#:

Normal CT – Axial plane

PT’s CT – Axial plane Accession#:

 Patient transferred to NSICU  Neuro exam temporarily improved with mannitol  Multiple units of platelets and FFP  Followed by acute decline in neurological exam  Physical exam – dilated, unreacting R pupil + extensor posturing, pt hypeventilating and active bleeding from central line  Stat CT ordered Clinical course

PT’s CT – Sagittal plane Accession#:

Previous CT – Sagittal plane Accession#:

PT’s CT – Coronal plane Accession#:

Previous CT – Coronal plane MRN:

PT’s CT – Axial plane Accession#:

Previous CT – Axial plane Accession#:

 Includes both medical and surgical options  Patient should be cared for in an ICU setting  If have fever, should be treated with antipyretic  Maintenance fluids with normal saline; hypotonic fluids can exacerbate edema and ICP.  Reverse any anticoagulation  Control BP  Elevate bed to 30 degrees to dec ICP  Sedation to dec ICP [propofol]  Mannitol  Surgery Treatment

 Neurosurg was consulted, surgery was not indicated  Mannitol did not help improve mental status,  Patient remained intubated, sedated, and unresponsive  Palliative care came on board, family made decision to withdraw care Clinical course

 Hematoma growth – particularly within first 24 hours; independent predictor of mortality and poor outcome [10% growth, 5% death]  Intraventricular and subarachnoid extension – Also an independent predictor Prognosis

 Rodriguez-Luna D, Rubiera M, Ribo M, et al. Ultraearly hematoma growth predicts poor outcome after acute intracerebral hemorrhage. Neurology 2011; 77:1599.  Hallevi H, Albright KC, Aronowski J, et al. Intraventricular hemorrhage: Anatomic relationships and clinical implications. Neurology 2008; 70:848  Kidwell CS, Chalela JA, Saver JL, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA 2004; 292:1823.  Kidwell CS, Wintermark M. Imaging of intracranial haemorrhage. Lancet Neurol 2008; 7:256. References