FERNE On-Line CME Program

Optimizing the ED Management of
Intracerebral Hemorrhage Patients

Please circle the correct answer.

Questions

1. All of the following are true regarding the presentation of intracerebral hemorrhage patients except:
a. Many elderly ICH patients suffer from cerebral amyloid angiopathy.  
b. Hypertension is a common risk factor for intracerebral hemorrhage.
c. Altered mental status, headache, and vomiting are more common in patients who present with ICH than     those who present with acute ischemic stroke.
d. Seizures occur in the majority of patients who present with an ICH.
e. ICH patients frequently present with poorly controlled hypertension.

2. All of the following are true regarding disease progression and outcome in ICH patients except:
a. Hemorrhage volume remains relatively constant over time in ICH patients.
b. Large hemorrhage volume and low Glasgow Coma Scale (GCS) score are associated with a worse     outcome following ICH.
c. The presence of intra-ventricular hemorrhage and hydrocephalus are associated with a worse outcome     following ICH.
d. Deterioration in mental status and lower GCS scores are associated with an increase in hemorrhage     volume over time.
e. Hematoma volume can be accurately estimated using non-contrast cranial CT.

3. All of the following are true regarding spontaneous ICH management guidelines except:
a. The AHA has a published scientific statement on the management of patients with spontaneous ICH.
b. Blood pressure, glucose and hyperthermia control are key acute care components in the ED.
c. MAP control to levels below 130 mmHg is essential, as is avoiding hypotension (SBP < 90 mmHg).
d. Steroids are not indicated in the acute management of ED ICH patients.
e. Angiography is most often indicated acutely in the ED management of ICH patients.

4. All of the following are true regarding intracranial pressure (ICP) management in acute ICH patients except:
a. Cerebral perfusion pressure is the difference between mean arterial pressure (MAP) and     [CPP=MAP-ICP].
b. Elevated ICP is defined as an ICP > 20 mmHg for more than 5 minutes.
c. Normal cerebral perfusion pressure should be above 30 mmHg.
d. Patient head positioning, osmotherapy, hyperventilation, and ventricular drainage are all viable means of     lowering elevated ICP in ICH patients.
e. ICP monitoring is recommended in ICH patients with a GCS score < 9.

5. All of the following are true regarding the indications for operative intervention for ICH patients except:
a. Cerebellar hemorrhage three cm or greater in diameter or associated with significant posterior fossa     mass effect.
b. ICH that is located deep within the brain as opposed to those that are located on the superficial cerebral     cortex.
c. Although the STICH trial suggests limited value to operative intervention for ICH patients, very early     intervention may still be of value in improving patient outcome.   
d. Young ICH patients that quickly deteriorate may benefit most from early operative intervention.
e. Despite early operative intervention for ICH patients, the expected mortality based on clinical trials data     suggests mortality in excess of 75%.

6. All of the following are true regarding cranial non-contrast CT in the acute diagnosis of stroke and ICH patients except:
a. CT is useful in determining mass effect and signs of herniation.
b. Skull fracture can usually be detected on CT, as long as bone windows are specifically viewed.
c. Findings such as neoplasms, infectious lesions, or isodense subdurals may only be observed in the     presence of significant edema and/or mass effect.
d. Signs of ischemia may only be present several hours after the acute event, and may require a repeat CT     or MRI in order to detect the ischemic stroke lesion.
e. MRI is the gold standard for determining the presence of hemorrhage in acute stroke patients.

7. All of the following are true regarding the use of advanced CT and MR diagnostics in the ED evaluation     of stroke and ICH patients except:
a. MRI may be more useful than CT in the detection of acute CNS inflammation.
b. Although not required to be used rather than CT, MRI in the ED is most often indicated in the setting of     suspected spinal cord compression.
c. MR venography is useful in the detection of dural venous sinus thrombosis.
d. CTA and MRA are useful in the visualization of the CNS vasculature, and have replaced angiography as     the gold standard neuroimaging modality.
e. CTA and multi-modal MRI may be useful in determining ischemic stroke patient therapies because they     identify the presence and size of the ischemic penumbra.

8. All of the following true regarding oral anticoagulant therapy (OAT) induced ICH except:
a. ICH risk is up to 10 fold greater for patients over age 50 who are on an oral anticoagulant.
b. ICH risk is especially great if the INR is greater than 4.
c. Most patients with a OAT-associated ICH have an INR in the normal range.
d. OAT-associated ICH is most commonly seen after patients have been on the anticoagulant for a long     period of time.
e. The risk of ICH hemorrhage growth is greater for patients with OAT-associated ICH than for patients     whose ICH is not associated with the use of an anticoagulant.

9. All of the following are true regarding the treatment of patients with ICH related to oral anticoagulants     except:
a. 2001 Guidelines published in Chest describe the optimal care of patients with and elevated INR.
b. Significant cut-offs associated with increased ICH and bleeding risk are seen at INRs greater than four     and greater that nine.
c. Vitamin K is the initial therapy to be used in treating ICH patients with an elevated INR, and the IV route     is recommended if the hemorrhage is life-threatening.
d. One of the key requirements for emergency physicians as they treat ICH patients with an elevated INR is     to determine the need for acute operative intervention as the INR is being corrected.
e. Although fresh frozen plasma, prothrombin complex concentrate, and Factor VIIa all can be used to treat     OAT-associated ICH, the faster response to therapy is seen with the use of FFP.

10. All of the following are true regarding the use of recombinant Factor VIIa in the treatment of ICH       patients except:
a. Recombinant FVIIa has a relatively long half-life, in the range of 24-36 hours.
b. Recombinant FVIIa works through factor X activation, which leads to thrombin and fibrin formation,     allowing an effective clot to form. 
c. Elevated INR levels can be relatively quickly restored with the use of recombinant FVIIa in ICH patients.  
d. Thromboembolic complications can occur with the use of recombinant FVIIa, such that its use must be     carefully considered, even in patients with an elevated INR and ICH.
e. The use of recombinant FVIIa in the setting of ICH, even those that are OAT-associated, is not yet FDA     approved while a confirmatory phase III trial is being completed.