Micro bleed
-
Upload
bipin-bhimani -
Category
Health & Medicine
-
view
82 -
download
2
Transcript of Micro bleed
Dr.Bipin Bhimani M.D.,D.M.
Consultant Neurophysician
Well care Hospital
Rajkot
Case :• M / 44 yrs• Sudden onset of Weakness/ Clumsiness/ giving away of both LLS• About to fall but was supported• Lasted for few minutes (2-5 minutes)• ? Sensory ( numbness)• Recovered totally.
• RHD/MS/BMV done 1 month ago• No AF/ clot/ LA-near ok / no smoke• Past h/o ? Cerebellar Stroke 2 yrs back (Admitted/No reports available) • Ecospirin OD/150mg
• ? Spinal cord TIA• ? Cerebral TIA• ? Symptomatic microbleed
• Normal course: admission, observation Repeat ECHO heparinisation anticoagulants• Any change in view of multiple micro bleeds ?
Affects many therapeutical decisions
• Aspirin• Clopidogrel• Asp +Dypiridamole • Asp+ Clop• Asp+Clop+cilastazol• Anticoagulants /Heparin• tPA
CMBs/BMBs
• Mid 1990s • Focal hemosiderin,DOHb,Ferittin
(macrophage)of previous hemorrhage• ( perivascular)• < 5 mm round (actually smaller)• Usually BG/ SC , in CAA cortical • Also cerelellum, brain stem • Persists for many years
• Fibrohyalinosis or CAA, <200 micrometer vessel rupture
• Gradient Echo ( focal areas of signal loss) T2• Susptibility Weighted –better
Cortical (CAA) Vs SC (HT)
Criteria of CMBs
• 1 Black lesions on T2*-weighted MRI• 2 Round or ovoid lesions (rather than linear)• 3 Blooming effect on T2*-weighted MRI*• 4 Devoid of signal hyperintensity on T1- or T2• 5 At least half the lesion surrounded by brain
parenchyma • 6 Distinct from other potential mimics such as iron
or calcium deposits • 7 Clinical history excluding traumatic DAI
CMBs are seen in
• Healthy adults • Healthy elderly• Lacunar and other ischemic strokes• ICH• Cerebral amyloid angiopathy• CADASIL • Some genetic collagen disease• Alz disease• Moyamoya disease
Associations
• Older age• Asian • Male • HT ?DM • Smoking• White matter disease• ICH• Lacunes/Ischemic strokes • Low cholestrol (?)
• 53 yrs ----3.1%• 60 yrs ----6%• HT – • Male more • Ischemic -34%• Hemorrhagic-60%• Alz-20%• Much more in recurrent strokes
Benign or pathological • Small vessel disease• Further Stroke burden • ( ischemic/hemorrhagic)• More bleed size• Increase Hemorrhagic transformation of infarcts • Executive dysfunction• Cognitive decline • Further future events in CAA• New bleed accumulates over time
CMB detection
• Tesla (field strength)• Echo time • Flip angle • Slice thickness
Scores:
• MARS- Microbleed Anatomical Rating Scale
• BOMBs- Brain Observer Micro Bleed Scale
DDs
• Micro hemorrhagic mets• Calcium /iron ( symmetrical )• Cerebral Cavernoma (rare, hereditary)• Capillary telangiectasias • Leptomeningial hemosiderosis• Vascular flow voids (can trace vessel course)• Diffuse Axonal injury ( trauma )
Prevention
• Anti HT ( peri/Indapa)• Cessation of smoking
• Avoid anticoagulants
Is CMBs symptomatic?
• Acute –usually no symptoms ,occ seizure by irritation of brain parencyma , occ focal symptoms
• Chronic- executive dysfunction
• Not an innocent bystander
Suspected acute symptomatic CMBs
paradox
• In some recurrent “TIA” like cases, incressing dose of antiplatelets or adding new one exacerbates problem…while reducing antiplatelets or anti-convulsants solve the problems!
CMBs and anti-thrombotics
• Should not be withheld
• Do not withheld aspirin
• Avoid double esp if multiple/Lobar CMBs
CMBs and anticoagulants
• Avoid anticoagulation or double anti platelets in CAA ( multiple, lobar)
Warfarin ICH and CMBs
CMBs and tPA
• MR is usually not done• Go ahead• Minor Contraindication• Statistically insignificant trend of increase ICH • Symptomatic ICH rare
Thank you