Title: Optimizing the Management of Emergency Department Intracerebral Hemorrhage Patients FERNE Satellite 2005 ACEP Scientific Assembly Washington, DC 2005
1Optimizing the Management of Emergency
Department Intracerebral Hemorrhage
PatientsFERNE Satellite2005 ACEP Scientific
AssemblyWashington, DC 2005
2Head CT Interpretation in the ED The Complete
Primer
Brian A. Stettler, MD Assistant
Professor Department of Emergency
Medicine University of Cincinnati
3Objectives
- 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
4Clinical 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
5ED 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
6ED 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
7Points 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?
8Non-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
9Non-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
10Non-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
11Head 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
12Head CT Interpretation
- Look at the scout
- Adequate study?
- Minimize motion
- Subject to artifact from metal
13Head CT Interpretation
- Quick look
- Get the gestalt
- Assess for gross abnormalities
14Head CT Interpretation
- Extra-axial hemorrhage
- Epidural hematoma
- Subdural hematoma
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
- Intraventricular hemorrhage
15Epidural Hematoma
- Lens shaped
- Does not cross suture lines
- Typically acute or hyperacute
- Frequently associated with mass effect
16Subdural Hematoma
- Located along calvarium, falx, tentorium
- Crosses suture lines, usually spreads more
extensively than epidural
Acute
17Subdural 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
18Subdural 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
19Subarachnoid 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
20Subarachnoid Hemorrhage
- Source
- Post-traumatic
- Aneurysmal
- AVM
- Other
- Hounsfield units
- Blood is 50-100 (80)
21Intracerebral 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
22Intracerebral 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
23Volume 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
24Mass 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
25Herniation
- 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
26Tying it Together
- Spontaneous ICH
- Supratentorial (L basal ganglia)
- Approx 45cc
- 8mm of midline shift
- Evidence of uncal herniation
27Trauma - 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
28Trauma - 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
29Ischemia
- 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
30Ischemia
- 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
31Ischemia
- 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
32Being 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
33Being 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
34Case 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
35Head 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
36Head 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
37Head 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
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