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Chapter 1. Ischemic and Hemorrhagic Stroke

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A 72-year-old woman with a history of uncontrolled hypertension presents to the emergency department with a severe headache, blurry vision, and slurred speech. Initial blood pressure is 238/109 mm Hg. Emergent head computed tomography (CT) shows a cerebellar vermis hemorrhage measuring 4 cm with significant compression of the brainstem and encroachment of the fourth ventricle. Coagulopathy studies and platelets are normal. She is not taking any antithrombotic therapies. Shortly thereafter, she becomes obtunded and requires intubation. Which of the following treatments is most likely to improve outcome?

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A. Acute reduction in blood pressure

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B. Empiric platelet transfusion

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C. Emergent posterior decompressive craniotomy

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D. Hyperosmotic therapy

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E. Placement of an external ventricular drain (EVD)

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C. The 2015 American Heart Association Guildelines on management of intracerebral hemorrahge provide class 1 recommendation (level of evidence B) for management of cerebellar hemorrhage. In patients with clinical deterioration and evidence of brainstem compression due to a cerebellar hemorrhage, regardless of the largest diameter, decompressive surgery should be performed. The recommendations also advise against placement of an external ventricular drain prior to definitive surgical intervention (level III, class C).

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Acute reduction in blood pressure has not been convincingly shown to improve outcomes. Specifically for this patient, neither the ATACH2 trial, as this is a posterior fossa hemorrhage, nor the INTERACT2 trial, as the patient requires emergent surgery, applies. Therapeutic hypothermia has not been proven to be effective in intraparenchymal hemorrhage. Platelet transfusion would not be indicated in someone with normal platelet levels, and even in patients on antiplatelet therapy, the evidence for empiric platelet transfusion is not supported. Hyperosmotic therapy may temporarily treat cerebral edema, but a more definitive intervention is needed.

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A 59-year-old African American man with a history of hypertension presents to the emergency department with acute onset of headache, nausea, vomiting, right-sided weakness, and numbness. Initial blood pressure is 201/103 mm Hg. Initial Glasgow coma scale (GCS) score is 14. Emergent CT of the head shows a left thalamic intraparenchymal hemorrhage with intraventricular extension and no hydrocephalus. The calculated volume of the hematoma is 8 mL (based on the ABC/2 formula). Based on the data provided, what is this patient’s intracerebral hemorrhage (ICH) score?

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A. 0

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B. 1

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C. 2

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D. 3

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E. 4

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B. The ICH score is a clinical grading scale and can be useful in estimating 30-day mortality. The scale ranges from 0 ...

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