Spontaneous Intracerebral Hemorrhage
- Basal ganglia > thalamus > white matter > pons > cerebellum
- No large areas of necrosis (vs. infarcts)
- May dissect into ventricles, subarachnoid space
- Duret hemorrhage if herniation occurs
Ultimately resorbed leaving fluid filled cavity
Saccular “Berry” Aneurysms
- Less common than ICH
- Most common cause of spontaneous subarachnoid hemorrhage
- Affects 1% of population
- Polycystic kidney disease, fibromuscular dysplasia, coarctation of aorta, arteriovenous malformation
- Congenital defect of arterial wall (media) at branch points (80%)
- 80% at bifurcations of anterior circulation
- 15-20% posterior circulation
- 25% multiple
- Local mass effect
- Rupture into subarachnoid space
- Rupture into brain
- Secondary infarcts due to arterial spasm
- Younger females (< 50)
- Abrupt onset of signs of raised intracranial pressure
- Meningeal signs (bloody CSF)
- 50% die within days
- Infarcts after 4-9 days
- Hydrocephalus (organization may cause obstruction)
Source: Inflammatory Bowel Diseases
- Inflammation of the appendix that lead to infection (abscess) and/or perforation if not recognized and treated appropriately
**Most common abdominal surgical emergency**
- Most common in ages between 10 – 30
- lymphoid hyperplasia,
- fecalith obstruction (hardening of feces into lumps of varying size inside)
- Perforation occurs in about 20%
- Initial symptom is intermittent periumbilical or epigastric pain.
- Then localizes to the RLQ (McBurney’s point) and becomes constant
- Pain is worsened by movement
- Nausea and anorexia
- Low-grade fever
Specific localization of tenderness to McBurney’s point indicates that inflammation is no longer limited to the lumen of the bowel (which localizes pain poorly), and is irritating the lining of the peritoneum at the place where the peritoneum comes into contact with the appendix.
PHYSICAL EXAM FINDINGS
- Abdominal rebound tenderness and guarding
- Positive Psoas sign (pain with raising a straight leg with resistance)
- Positive Obturator’s sign (pain with flexed right hip rotation)
- Sometimes pt may have RLQ pain on palpation of LLQ
Pain is elicited by performing the psoas test by passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip. If abdominal pain results, it is a “positive psoas sign“.
The pain results because the psoas borders the peritoneal cavity, so stretching (by hyperextension at the hip) or contraction (by flexion of the hip) of the muscles causes friction against nearby inflamed tissues. In particular, the right iliopsoas muscle lies under the appendix when the patient is supine, so a positive psoas sign on the right may suggest appendicitis. A positive psoas sign may also be present in a patient with a psoas abscess
Obturator’s sign: If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internal rotation of the hip. This maneuver will cause pain in the vagina hypogastrium.
- Gynecologic Disorders
- Ectopic pregnancy
- Kidney stones
- Mechanical obstruction
CT is choice diagnostic test***
- Microscopic hematuria and pyuria may be seen
- Radiographic finding of free air suggests perforation
- Appendectomy: laparoscopic – longer surgery time than open surgery, shorter recovery time, and less infectious complication
- Antibiotics may be indicated prior to surgery
ITP is a disorder of increased platelet destruction caused by the development of platelet autoantibodies. ETIOLOGY/ PATHOGENESIS Also known as isolated thrombocytopenia, ITP is a diagnosis of exclu…
ITP is a disorder of increased platelet destruction caused by the development of platelet autoantibodies.
- Also known as isolated thrombocytopenia, ITP is a diagnosis of exclusion.
- It occurs in children as acute ITP, typically follows an acute viral or upper respiratory infection, and resolves spontaneously within several months.
- In adults it occurs as chronic ITP and affects more women than men in a 3:1 ratio.
- Spontaneous remission in adults is rare.
- Intracranial hemorrhage is the most significant complication.
- Children often present with sudden onset of bruising and petechiae
- Adults may have history of easy bruising
- Women may have history of menometrorrhagia
PHYSICAL EXAM FINDINGS
- In adults physical exam is usually normal.
- Patients may present with epistaxis, gingival bleeding or ecchymosis
- Myelodysplastic diseases
- Lymphoproliferative diseases
- Complete blood count: thrombocytopenia; large platelets on peripheral smear
- PT/aPTT: normal
- Bone marrow examination in chronic ITP
- ANA in patients with chronic TTP to rule out SLE
- Platelet count is often less than 30×109/L at the time of diagnosis.
- In chronic ITP a bone marrow examination is performed to rule out other causes of thrombocytopenia. In ITP the bone marrow has increased numbers of megakaryocytes.
- Treatment is not usually initiated unless platelet count is <20,000/µL except in cases of hemorrhage.
- Prednisone will increase platelet count and possibly decrease autoantibody production
- Splenectomy in patients not responsive to prednisone
- Immunosuppressive drugs in patients not responding after splenectomy or in relapse after initial therapy
- IV gamma globulin (IVIgG) is known to temporarily increase platelet counts
PATIENT EDUCATION/ MAINTENANCE – PREVENTION
- Avoid contact sports/activities associated with high incidence of trauma
Avoid ASA products
Spontaneous Intracerebral Hemorrhage & Saccular “Berry” Aneurysms. Source: Spontaneous Intracerebral Hemorrhage & Saccular “Berry” Aneurysms