1. Intracerebral hemorrhage (ICH) accounts for _____ to _____% of strokes.

15 to 30%

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2. Complete the following regarding incidence of intracerebral hemorrhage in adults:

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a. In 100,000 people incidence is _____ to _____ cases per year.

12 to 15

b. Relative to subarachnoid hemorrhage (SAH) it is _____ times as frequent.

2

c. More cases occur in which sex?

males

3. True or False. The following are risk factors for ICH:

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a. age

true

b. gender

true (M > F)

c. race

true (black > white)

d. recent ETOH

true

e. chronic ETOH

true

f. cigarettes

false

4. True or False. The following increases the incidence of cerebral hemorrhage:

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a. alcohol, amyloid angiopathy, age

true

b. birefringence

true

c. Charcot-Bouchard aneurysms

true

d. carotid disease

true

e. central nervous system (CNS) infection

true

f. cerebrovascular accident (CVA) previously

true

g. street drugs

true

h. male gender

true

i. liver disease

true

j. race

true

k. smoking

false

5. For hypertensive hemorrhage sites of predilection are

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a. s_____;_____%

striate body (basal ganglia); 50% (putamen, lenticular nucleus, internal capsule, globus pallidus)

b. t_____;_____%

thalamus; 15%

c. p_____;_____%

pons; 10%

d. c_____;_____%

cerebellum; 10%

e. c_____w_____m_____;_____%

cerebral white matter; 10%

f. b_____s_____;_____%

brain stem; 5%

6. Complete the following regarding intracerebral hemorrhage in adults:

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a. The number one location for deep ICH is_____

putamen

b. from rupture of_____ _____.

lenticulostriate arteries

7. Complete the following regarding intracerebral hemorrhage in adults:

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a. Incidence of lobar hemorrhages is_____to_____%.

10 to 30%

b. Is lobar or deep more fatal?

deep

c. Which is more related to alcohol?

lobar

8. Complete the following regarding lobar hemorrhage:

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a. Incidence per 100,000 is_____to_____.

2 to 10(10to30% of the 15 to 30% of hemorrhagic CVAs)

b. Compared with deep hemorrhages, lobar hemorrhages have a_____prognosis.

better

c. Hemorrhagic transformation may occur in

     i._____% of CVAs

43%

     ii. in time from_____to_____.

1 day to 1 month

9. List the causes of lobar hemorrhage.

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Hint: teach it

a. t_____

tumor

b. e_____

extension of deep ICH

c. a_____

amyloid angiopathy

d. c_____

cerebrovascular malformation or aneurysm

e. h_____

hemorrhagic conversion of ischemic stroke

f. i_____

idiopathic

g. t_____

trauma

10. Hemorrhagic transformation of an ischemic infarct

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a. is estimated to occur in_____%

43%

b. within the first_____

month

c. and may occur within_____hours.

24

11. True or False. The incidence of symptomatic ICH within 36 hours of tissue plasminogen activator (t-PA) treatment for acute ischemic CVA is approximately

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a. < 1%

false

b. 6%

true(The incidence is 6.4% versus 0.6% for placebo.)

c. 15%

false

d. 30%

false

12. What types of infection predispose to cerebral hemorrhage?

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a. f_____

fungal

b. g_____

granulomas

c. h_____s_____

herpes simplex

13. True or False. Cocaine/amphetamine can cause

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a. ischemic CVA

true

b. ICH

true

14. Complete the following regarding intracerebral hemorrhage in adults:

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a. Hypertension is a risk factor for hemorrhage in which locations?

     i. p_____

pontine ICH

     ii. c_____

cerebellar ICH

     iii. b_____g_____h_____

basal ganglia hemorrhages (65%)

b. Not a risk factor for_____%

35% of basal ganglia hemorrhages

15. Complete the following regarding intracerebral hemorrhage in adults:

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a. Lobar hemorrhages are associated with_____ _____

amyloid angiopathy

     i. also known as_____ _____

congophilic angiopathy

     ii. deposit of_____ _____

beta amyloid

     iii. appears on polarized light as_____

birefringent—apple green color

b. Responsible for_____% of cases of ICH

10%

c. Any genetic factors?

yes

d. If so, what? Apoli protein E e4 allele

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e. How does this affect patients clinically? those with APOE have hemorrhage 5 years earlier

16. True or False. Cerebral amyloid angiopathy is associated with systemic amyloidosis.

false (It does not require systemic amyloidosis.)

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17. Recurrent lobar hemorrhages should suggest a diagnosis of c_____a_____a_____.

cerebral amyloid angiopathy

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18. Malignant tumors associated with ICH include

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a. primary (name two)

     i. g_____m_____

glioblastoma multiforme

     ii. l_____

lymphoma

b. metastatic (name four)

     i. l_____

lung (Only approximately 9% hemorrhage but is so much more common than the others that it is seen the most.)

     ii. ch_____

choriocarcinoma (approximately 60% bleed)

     iii. m_____

melanoma (approximately 40% bleed)

     iv. r_____

renal cell carcinoma

19. Complete the following regarding anticoagulation preceding ICH:

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a. Incidence of bleeding complications in patients on anticoagulation is_____% per year.

10%

b. Incidence of ICH is_____.

0.3 to 1.8% per year; 3 to 18/1000

c. Mortality in the ICH group is_____.

65%; 2 to 12/1000 die each year

20. True or False. Transient ischemic attack (TIA)— like symptoms precede lobar ICH in patients with amyloid angiopathy ~50% of the time.

true(But these have Jacksonian-March-style numbness, weakness, or tingling.)

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21. What is the most common site for intracerebral hemorrhage?

putamen

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22. Complete the following regarding ICH with thalamic hemorrhage:

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a. Clinically usually found to have_____loss.

hemisensory loss(contralaterally)

b. Any motor function loss?

yes(hemiparesis if internal capsule compressed)

c. Any eye signs such as anisocoria or miosis?

yes(with upper brain stem extension)

d. Beyond what size has high mortality?

3.3 cm in diameter(i.e., 18 cc)

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23. True or False. Cerebellar hematomas

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a. produce hemiparesis before coma

false

b. produce coma before hemiparesis

true(because of compression of the brain stem)

c. do not produce coma or hemiparesis

false

24. Answer the following about rebleeding after intracerebral hematoma:

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a. True or False. It occurs more frequently in basal ganglia hemorrhages than lobar.

true

b. True or False. It occurs most frequently on the second day.

false(most commonly within the first hour)

c. True or False. Incidence increases with time.

false (decreases with time)

d. True or False. It is more common with small hemorrhages.

false (more common with large hemorrhages)

e. True or False. It is more likely if there is a coagulopathy.

true

f. Early rebleeding can occur in_____%.

33 to 38%(in 1 to 3 hours)

g. Late rebleeding can occur in_____%.

1.8 to 5.3%

25. The component that is released by clot and presumed to be the most likely cause of surrounding delayed edema and deterioration is_____.

thrombin

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26. What is the formula for volume of a hematoma?

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a. sphere V =_____

V = π D3 ÷ 6 for a sphere

b. ellipse V =_____

V = π (h × w × d) ÷ 6 for ellipse

c. modified V =_____

V = h × w × d ÷ 2 modified

27. What equation can be used to estimate the volume of an ICH?

(A × B × C) ÷ 2 modified ellipsoid volume where A, B, and C are the diameters of the clot in each of the three dimensions

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28. Complete the following regarding intracerebral hemorrhage in adults:

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a. An average size of a clot decreases at the rate of_____ mm/day.

0.75

b. The density decreases by_____Hounsfield units (HU) per day.

2

c. There is_____change for the first

little

d._____weeks.

2

29. List the sequence of hemoglobin evolution after intracerebral hemorrhage.

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Hint: On days my mom’s home

a. o_____ 0 to 1 day

oxyhemoglobin

b. d_____ 1 to 3

deoxyhemoglobin

c. m_____ 3 to 7

methemoglobin

d. m_____ 7 to 14

methemoglobin

e. h_____ 14-plus

hemosiderin

30. Give the ICH scores for the following:

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a. Glasgow coma scale (GCS)

     i. finding 3 to 4 points_____

2

     ii. finding 5 to 12 points_____

1

     iii. finding 13 to 15 points_____

0

b. location

     i. finding infratentorial points_____

1

     ii. finding supratentorial points_____

0

c. age

     i. finding > 80 years points_____

1

     ii. finding < 80 years points_____

0

d. volume

     i. finding > 30 cc points_____

1

     ii. finding < 30 cc points_____

0

e. intraventricular

     i. finding yes points_____

1

     ii. finding no points_____

0

31. ICH score vs mortality

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a. points 0 mortality in 30 days_____rounded out_____

points 0, mortality in 30 days 0%, rounded out 0

b. points 1 mortality in 30 days_____rounded out_____

points 1, mortality in 30 days 13%, rounded out 10

c. points 2 mortality in 30 days_____rounded out_____

points 2, mortality in 30 days 26%, rounded out 30

d. points 3 mortality in 30 days_____rounded out_____

points 3, mortality in 30 days 72%, rounded out 70

e. points 4 mortality in 30 days_____rounded out_____

points 4, mortality in 30 days 97%, rounded out 90

f. points 5 mortality in 30 days_____rounded out_____

points 5, mortality in 30 days 100%, rounded out 100

g. points 6 mortality in 30 days_____rounded out_____

points 6, mortality in 30 days rounded out 100

32. Complete the following about management of ICH:

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a. Blood pressure (BP) permissible to reduce mean arterial pressure (MAP) by_____%.

20%

b. Target level BP is_____and diastolic_____.

140 and diastolic; 90

33. Matching. Match the percent yield for finding AVM or aneurysm on angiogram in the following patients:

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0%; 10%; 65%

a. patient > 45 years old + hypertension (HTN)lobar ICH

b. patient > 45 years old + HTN thalamic putamen ICH cerebellar/pons

c. patient with intraventricular hemorrhage (IVH) without parenchymal hemorrhage

34. When is it appropriate to restart anticoagulation after cerebral hemorrhage?

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a. If there is a strong indication restart in_____days.

5

b. If Coumadin is stopped for 10 days the chance of stroke within 30 days in a patient with

     i. prosthetic heart value is_____%

2.5%

     ii. atrial fibrillation is_____%

2.6%

     iii. cardioembolic stroke is_____%

4.8%

c. The basic recommendation is to stay off blood thinners for_____.

2 weeks

d. If the patient needs dialysis, use h_____-f_____ d_____.

heparin-free dialysis

35. True or False. The volume of hematoma on which it is usually most appropriate to operate is

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a. < 10 cc

false (< 10 cc too small; no major mass effect)

b. 10 to 30 cc

true

c. > 30 cc

false(usually a poor outcome)

d. > 85 cc

false (no survivors)

36. True or False. Surgical treatment for cerebellar ICH is recommended for

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a. GCS 14, hematoma 3 cm diameter

false(may treat conservatively 14 cc)

b. GCS 13, hematoma 4 cm diameter

true(Surgical treatment is recommended for GCS ≤ 13 or hematoma ≤ 4 cm diameter = 32 cc.)

c. GCS 3

false(not in the face of complete neurologic destruction where the outcome will be poor [i.e., flaccid, no brain stem reflex])

d. hematoma plus hydrocephalus

true

37. With cerebral hemorrhage, the possible mortality in 30 days for the following conditions is

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a. SAH_____%

46%

b. ICH-basal ganglia thalamus_____%

44%

c. ICH-lobar_____%

11%