Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005 - PowerPoint PPT Presentation

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Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005

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Title: Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005


1
Optimizing the Management of Emergency
Department Intracerebral Hemorrhage
PatientsFERNE Satellite2005 ACEP Scientific
AssemblyWashington, DC 2005
2
Head CT Interpretation in the ED The Complete
Primer
Brian A. Stettler, MD Assistant
Professor Department of Emergency
Medicine University of Cincinnati
3
Objectives
  • Discuss the utility of Head CT
  • Discuss what Head CT will miss
  • Review basic interpretation of the Head CT
  • Discuss a few specific disease processes

4
Clinical History
  • CC Headache and weakness
  • HPI 67 year old female with several months of
    dull headaches relieved by Tylenol and subjective
    dizziness without falls. Symptoms worsened
    today about 2 hours ago and she now complains she
    cannot walk secondary to dizziness

5
ED Presentation
  • PMHx DM, HTN, CAD
  • Meds Atenolol, HCTZ, ASA, Insulin
  • All NKDA
  • SocHx 1PPD, Occasional Etoh, denies drugs
  • ROS mild anorexia, weight loss approx 5 lbs over
    past month, o/w neg

6
ED Presentation
  • PE 176/94, 65, 16, 98.8, 93 RA
  • Gen alert and conversive, sl uncomfortable
    appearing
  • HEENT WNL
  • Pulm sl wheezes, otherwise WNL
  • CV WNL
  • Neuro strength 4/5 throughout, gait unsteady
    without overt ataxia, no deficits to cranial
    nerves

7
Points of Discussion
  • In addition to other labs, a non-contrast head CT
    is ordered
  • How is this study interpreted?
  • What findings affect the treatment of the
    patient?
  • What findings portend a bad outcome for the
    patient?

8
Non-contrast Head CT
  • The most common neuroimaging tool employed in the
    ED
  • Performed in seconds, usually read in minutes
  • No IV access required
  • Available 24 hours/day in most EDs
  • No real contraindications
  • Good sensitivity and specificity for many disease
    processes

9
Non-contrast Head CT
  • Benefits
  • Gold standard in assessment for acute hemorrhage
  • Very good at documenting mass effect and
    herniation
  • Will visualize acute ischemia, neoplasm,
    localized intracranial infection
  • Good at visualizing skull fracture

10
Non-contrast Head CT
  • Drawbacks
  • Poor at visualizing disease in the posterior
    cranial fossa, especially ischemia
  • Poor at diagnosing intracranial mass that does
    not have significant mass effect
  • Sensitivity is not high enough to completely
    eliminate SAH
  • Will miss delayed disease, such as delayed SDH

11
Head CT Interpretation
  • Scout, assessment for adequacy
  • Quick look
  • Detailed look (force yourself)
  • Extra-axial blood
  • Mass effect
  • Ischemia
  • Ventricles
  • Vessel density
  • Bone windows
  • Extras (sinuses, mastoids)
  • Compare to old

12
Head CT Interpretation
  • Look at the scout
  • Adequate study?
  • Minimize motion
  • Subject to artifact from metal

13
Head CT Interpretation
  • Quick look
  • Get the gestalt
  • Assess for gross abnormalities

14
Head CT Interpretation
  • Extra-axial hemorrhage
  • Epidural hematoma
  • Subdural hematoma
  • Subarachnoid hemorrhage
  • Intracerebral hemorrhage
  • Intraventricular hemorrhage

15
Epidural Hematoma
  • Lens shaped
  • Does not cross suture lines
  • Typically acute or hyperacute
  • Frequently associated with mass effect

16
Subdural Hematoma
  • Located along calvarium, falx, tentorium
  • Crosses suture lines, usually spreads more
    extensively than epidural

Acute
17
Subdural Hematoma
  • Can be acute, subacute, or chronic
  • Density on CT helps to age hematoma
  • Can frequently be a mix of ages
  • Can have mass effect that ranges from none to
    severe

Subacute
18
Subdural Hematoma
Chronic
  • Not all SDH are bright white
  • MUST follow gyri/sulci to edge of calvarium on
    every cut
  • Falx may be calcified but should be thin

Osborn, Diagnostic Imaging Brain 2004
19
Subarachnoid Hemorrhage
  • Can be present in cisterns, around gyri and sulci
  • Almost always acute
  • Sensitivity of NCHT
  • Not well known or agreed upon
  • Probably in the high 90s early
  • Decreases as time progresses from onset of
    symptoms

20
Subarachnoid Hemorrhage
  • Source
  • Post-traumatic
  • Aneurysmal
  • AVM
  • Other
  • Hounsfield units
  • Blood is 50-100 (80)

21
Intracerebral Hemorrhage
  • Location can be anywhere in the parenchyma
  • Can be caused by hypertension, AVM, amyloid
  • Typically present with headache, focal neurologic
    findings, AMS, N/V

22
Intracerebral hemorrhage
  • CT findings that affect outcome
  • Volume of hemorrhage
  • Location of hemorrhage (supra vs infratentorial)
  • Presence of intraventricular hemorrhage
  • Also describe
  • Presence of midline shift
  • Presence of herniation
  • Presence of hydrocephalus

23
Volume of Hemorrhage
  • (A x B x C)/2
  • A and B are perpendicular dimensions in the slice
    that shows the maximal amount of hemorrhage
  • C is the total number of slices that show
    hemorrhage x the slice thickness
  • Ex 4cm x 5.5 cm by (8 x 5mm slices)/2
  • 4 x 5.5 x 4/2 45cc

24
Mass Effect and Midline Shift
  • Mass effect can be local or generalized
  • When generalized, typically seen as shift of the
    midline structures away from the area of mass
    effect
  • Midline shift
  • Use drawing tools to draw line down center of
    skull
  • Measure from midline structure (pineal gland,
    falx, septum pellucidum) to line drawn

25
Herniation
  • Herniation is an ominous sign on CT
  • Types
  • Uncal (3rd nerve palsy the blown pupil)
  • Transtentorial
  • Sub-falcine
  • Tonsillar
  • Look for structures where they should not be

26
Tying it Together
  • Spontaneous ICH
  • Supratentorial (L basal ganglia)
  • Approx 45cc
  • 8mm of midline shift
  • Evidence of uncal herniation

27
Trauma - Contusions
  • Patchy hemorrhage contained to the superficial
    grey matter
  • Frequently associated with local edema
  • Caused by brain impact to bone
  • Locations most commonly temporal lobes and
    frontal, but can occur anywhere

28
Trauma - Contusions
  • Contusions frequently evolve from small petechiae
    to large areas of edema and hemorrhage over the
    course of 1-2 days

Osborn, Diagnostic Imaging Brain 2004
29
Ischemia
  • Very early CT typically negative
  • Early findings
  • Loss of grey-white differentiation
  • Insular ribbon
  • Basal ganglia/internal capsule
  • Effacement of ventricles and local mass effect
  • Hyperdense artery

30
Ischemia
  • Very early CT typically negative
  • Early findings
  • Loss of grey-white differentiation
  • Insular ribbon
  • Basal ganglia/internal capsule
  • Effacement of ventricles and local mass effect
  • Hyperdense artery

31
Ischemia
  • ASPECTS
  • Larger areas of grey-white changes on initial CT
    have worse outcomes
  • Score lt 7 had OR 82 for worse functional outcome

Barber, Lancet 2000
32
Being Thorough
  • Use bone windows on every trauma
  • Dont forget the extras
  • Sinuses, mastoid air cells
  • Air where it shouldnt be
  • Orbits
  • Old infarcts
  • If abnormal, look for an old CT

33
Being Thorough
  • Use bone windows on every trauma
  • Dont forget the extras
  • Sinuses, mastoid air cells
  • Air where it shouldnt be
  • Orbits
  • Old infarcts
  • If abnormal, look for an old CT

34
Case Follow-up
  • Pts CT showed a small, ill-defined parenchymal
    hemorrhage
  • Follow-up MRI showed multiple enhancing lesions
    suspicious for mets
  • Pt undergoing treatment for metastatic lung CA

35
Head CT - Conclusions
  • Scan early and often
  • Beware the lurking slit subdural
  • Contusions can be tiny at first
  • Ischemia can be subtle
  • You still cant completely trust the negative SAH
    CT
  • Negative early doesnt always mean negative late
    and vice versa

36
Head CT - Conclusions
  • Scan early and often
  • Beware the lurking slit subdural
  • Contusions can be tiny at first
  • Ischemia can be subtle
  • You still cant completely trust the negative SAH
    CT
  • Negative early doesnt always mean negative late
    and vice versa

37
Head CT - Conclusions
  • Useful imaging screening tool for many
    life-threatening neurologic processes
  • May miss early findings in hemorrhage or ischemia
  • Interpretation must be done thoroughly
  • The same way every time
  • Assess not only primary pathology, but factors
    contributing to outcome

38
  • Questions?

ferne_acep_2005_ich_stettler_ctdx_notes_100206
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