Spontaneous ICH caused by vascular abnormalities.pdf

Spontaneous ICH caused by vascular abnormalities.pdf

1. "Spontaneous Intracerebral
Hemorrhage, How to Determine the
EtiologyDue to Vascular Abnormalities"
Pinto Desti Ramadhoni, MD
Sriwijaya University, Faculty Of Medicines
Mohammad HoesinHospital

2. BurdenofIntracerebralHemorrhage(ICH)
•Epidemiology: ~10% of795,000 strokes/yearin theUS are ICH.
Disparities:
•1.6×morecommonin Black vs White.
•1.6×morecommonin MexicanAmerican vs non-HispanicWhite.
•Higherin low-andmiddle-incomevs high-incomecountries.
•Mortality: Deadliestacutestroke, 30–40% early-term mortality, little
improvementover time.
•RiskFactors: Olderage, hypertension, anticoagulantuse.,
malformation.

3. Global Incidence of Stroke Hemorrhagic
Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Feigin, Valery L et al. The Lancet Neurology, Volume 20, Issue 10, 795 -820

4. •GiventhehighburdenandmortalityofICH,thenext
crucialstepistoidentifyitsunderlyingcause,
especiallyvascularabnormalitiesthatmayguide
targetedtreatment.

6. Etiology
VascularCause:
Aneurysma
MalformasiArteri Vena
FistullaArteryVena
Cavernoma
CerebralAmyloidAngiopaty
(> 70 Yo)

7. Intracerebral Hemorrhage
Case 1
Case 2
Case 3
Vascular malformation
etiology?

8. Intracerebral Hemorrhage Location

9. DIAGRAM
Score

10. CTA (+) ??
•Intracranialaneurysm
•Arteriovenousmalformation(AVM)
•Duralarteriovenousfistula(dAVF)
•Moyamoyadisease/ severeintracranialstenosiswithfragile
collaterals
•Othermacrovascularlesions–e.g., cavernousmalformations,
hemangiomas, orotherrarevascularanomalies.
•“CTA inconclusiveshouldbeconsideredpositive.”

11. sICH Score
Determine structural vascular etiology of
intracerebral hamorrhage
High sensitivity and specificity (Validated)
Determine which case should be referred for
vascular imaging (CTA, MRA, DSA)

12. Case 1 ICH
Case 1:
Male 21 yo
Unconsious, right hemiparese
sICH Score:

13. Case 1: ICH

14. AVM Embolization

15. Case 2
Male 58 yo, history of Hipertention (+)

16. Case 3
•Male, 26 yo
•Unconsious, no history of
hypertension

17. sICH Score

20. •Lobar< 70 yo
•< 45 yoandDeep/posterior fossa
•45 –70 yo, deep/posterior fossawithouthistoryofHypertension
CTA + Venography

22. DSA

23. CTA / MRA (+) →DSA

24. CTA / MRI MRA inconclusive→DSA

25. CTA negative, butbasedonlocation, age, or
absenceofhypertension→ proceedwith
MRI/MRA → considercavernomaormalignancy

26. CTA/MRA maybeconsideredattheinitial
presentation

28. Male, 58 yo, HT

32. Female 19 yo,
eclamsia

33. Intracerebral Hemorrhage
Male 36 yo
Headache, Right
Homonimus
Hemianopsia

34. Dolicoecthasia / Disecting Fusiform
Aneurysm L PCA

35. •Male, 41 yo
•Right Hemiparesis at 1
st
onset
•No history of HT
•Hystory of Mixoma total resection
•2
nd
onset seizure and aphasia
Mixoma at achocardiography
Multiple Aneurysms ec Myxoma

36. After mixoma resection: no residual
mixoma

37. Multiple fusiform aneurysm

38. Diagnosed with SLE
treated in internal
medicine department
Consulted to
Neurology
Seizures, headache,
weakness of all four
extremities, tingling in
both arms and legs
History
Headache (+) throbbing
that is getting worse,
Hypertension (-), Diabetes
mellitus (-), heart disease (-
), kidney disease (-), head
trauma (-)
A female, 20 y.o, was admitted to the hospital due to a weakness on all of
the extremites
2019
5
th
April
2021
SLE, severe activity,
mucocutaneous
manifestations, lupus
nephritis, hematology.
9
th
April
2021
Metilprednisolon 8 mg/24
hr, Farneltik 1 tab/24 hr

39. HEAD CT
Non-contras Head CT scan on 10
th
April
2021
•Cerebral infarction right frontal, right lateral
periventricular (Venous Infarct ?)
•Right temporoparietal subarachnoid hemorrhagic

40. ADDITIONAL EXAMINATION
Head MRI on 15
th
April 2021
T1
T2
FLAIR
DWI

41. ADDITIONAL EXAMINATION
MRV

42. Iain J McGurgan et al. PractNeurol2021;21:128-136
©2021 by BMJ Publishing Group Ltd

43. CONCLUSION
Neurointerventionmakes it easier for us to make a
diagnosis in cases of Hemorrhagic Stroke whose
etiology was suspected vascular malformation.
Neurointerventionallows us to provide maximum
management of cases of cerebral/carotid vascular
disorders, not only in terms of prevention, but also
therapeutic.

44. CONCLUSION
•Neurologist must be able to determine the appropriate management
of hemorrhagic stroke cases to get a better clinical outcome, including
consideration for neurointerventional management

45. THANK YOU