Term
| where are the most common sites of *hypertensive intracerebral hemorrhage (ICH)? |
|
Definition
| 1) basal ganglia. 2) thalamus. 3) cerebellum. 4) pons. |
|
|
Term
| what is the most common cause of spontaneous lobar intracerebral hemorrhage in the elderly (60-65)? |
|
Definition
| amyloid angiopathy - which is also the 2nd most common cause of spontaneous intracerebral hemorrhage and is seen in association w/alzheimer's disease. it appears as deposition of congophilic material in small-medium sized blood vessels of the brain and leptomeninges. in its most severe stages, the amyloid deposits cause breakdown of the blood vessel wall w/resultant hemorrhage. many pts w/amyloid hemorrhage are normotensive. |
|
|
Term
| how does amyloid angiopathy compare to hypertensive hemorrhage in terms of location? |
|
Definition
| amyloid angiopathy is *intralobar and usually found in the frontal, occipital, temporal, or parietal lobe. hypertensive hemorrhage is found generally in the basal ganglia, thalamus, cerebrum and pons. |
|
|
Term
| what is the neurosurgical approach to CVA tx? |
|
Definition
| prevention of secondary injury, control of intracranial pressure, and protection of ischemic penumbra (avoiding hyperglycemia, hypercapnia, hypoxemia, hyper and hypotension) |
|
|
Term
| what is the monro-kellie doctrine? |
|
Definition
| if you increase the volume of something inside the head - it has to be at the expense of something else. *however up to a point the brain can accommodate by expelling CSF and venous blood. |
|
|
Term
| what is tx for elevated intracranial pressure (ICP - as seen in trauma, tumor, and stroke pts)? |
|
Definition
| sx (eliminate the cause), ventricular drainage (catheter), position of the head/neck (raise head+neck neutral), diuresis (osmotic like mannitol or non-osmotic like furosemide), steroids (only for brain tumor edema), hyperventilation (decrease in pCO2 reduces intracerebral blood volume w/o compromising blood flow), sedation/barbiturate coma (controls HTN), hypothermia, and glucose control (optimum level below 150) |
|
|
Term
| what 3 things do we need to know about a CVA? |
|
Definition
| the size of the hemorrhage, location and status of the pt. |
|
|
Term
| what is considered a small brain hemorrhage? what characterizes the response to them? |
|
Definition
| small hemorrhages are less than < 30 cc, which does not raise ICP enough to cause herniation syndromes. these do not require removal *unless it is surrounded by significant edema. |
|
|
Term
| when does spontaneous intracranial hemorrhage usually stop? |
|
Definition
|
|
Term
| why are big brain hemorrhages (w/ ventricular expansion) often not operated on? |
|
Definition
| even though these pts are neurologically devastated, sx does not provide expectation of a reasonable outcome. |
|
|
Term
| what characterizes dominant hemisphere hemorrhages? |
|
Definition
| dominant hemisphere hemorrhages are more devastating than non-dominant |
|
|
Term
| what characterizes the protocol for sx on cerebellar hemorrhage? what is the reason for this? |
|
Definition
| if there is a hemorrhage in the cerebellum larger than 3 cm, the pt goes to the operating room period. if the cerebellar hemorrhage is smaller than 3 cm, but the pt has an effaced/obstructed 4th ventricle or signs of dwindling consciousness - they also require sx. this is b/c cerebellar ICH can lead to obstructive hydrocephalus, brainstem compression (clivus), and occlusion of posterior circulation and strokes. |
|
|
Term
| can a non-hemorrhagic/bland stroke also cause ICP high enough to warrant sx? |
|
Definition
| yes - the size of these strokes can put as much pressure on the 4th ventricle as if it were a hemorrhage. |
|
|
Term
| what are the goals of surgical intervention in CVA? |
|
Definition
| acutely decrease ICP, prevent secondary injury to penumbra, and improve functional survival |
|
|
Term
| what is the sx tx for large supratentorial strokes, MCA and internal carotid stokes w/o hemorrhage? |
|
Definition
| decompressive hemicraniectomy - key have to do it early (when pt is getting a little more sleepy or the pupil is still dilating). this is a neurosurgical emergency reserved for patients who are not completely dead; who have large ischemic strokes, whose deficit is progressing so rapidly it cannot be treated medically. |
|
|
