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4/3: Elderly/Neuro Y3/4 - Neuro and Stroke [12] > [20] Subarachnoid Haemorrhage > Flashcards

[20] Subarachnoid Haemorrhage Flashcards

1
Q

What is a subarachnoid haemorrhage?

A

Bleeding into the subarachnoid space

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2
Q

What is the subarachnoid space?

A

The area between the arachnoid membrane and the pia mater surrounding the brain

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3
Q

What are subarachnoid haemorrhages usually a result of?

A

Bleeding from a berry aneurysm in the Circle of Willis

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4
Q

What percent of the population are berry aneurysms present in?

A

4%

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5
Q

Do most berry aneurysms rupture?

A

No

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6
Q

What causes development of berry aneurysms?

A

Susceptibility of the elastic lamina to stressors such as hypertension and atherosclerosis

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7
Q

What is another less common cause of subarachnoid haemorrhage?

A

Trauma

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8
Q

What are the risk factors for subarachnoid haemorrhage?

A
  • Hypertension
  • Smoking
  • Excessive alcohol consumption
  • Cocaine use
  • Genetic disorders
  • Family history
  • Age between 45-70
  • Female gender
  • Black ethnicity
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9
Q

What genetic disorders can predispose to subarachnoid haemorrhage?

A
  • Adult polycystic disease
  • Ehlers-Danlos Syndrome
  • Neurofibromatosis
  • Marfan’s Syndrome
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10
Q

Why might black ethnicity be a risk factor for subarachnoid haemorrhage?

A

They are at increased risk of hypertension

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11
Q

What is the most characteristic feature of a subarachnoid haemorrhage?

A

Sudden explosive headache

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12
Q

What is the sudden explosive headache of subarachnoid haemorrhage also known as?

A

Thunder clap headache

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13
Q

In what proportion of patients is a thunder clap headache the only symptom of subarachnoid haemorrhage?

A

1/3

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14
Q

Is the thunder clap headache more commonly distinguished by its severity or location?

A

Severity

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15
Q

What are some other possible presenting symptoms of subarachnoid haemorrhage?

A
  • Stiff neck
  • N&V
  • Photophobia
  • Diplopia
  • Stroke-like symptoms
  • Seizures
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16
Q

What may occur 3 weeks prior to subarachnoid haemorrhage?

A

Warning signs and symptoms

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17
Q

What are the warning signs and symptoms of subarachnoid haemorrhage related to?

A

Small leaks

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18
Q

What are the warning signs and symptoms of subarachnoid haemorrhage?

A
  • Headaches
  • Dizziness
  • Orbital pain
  • Diplopia
  • Visual loss
  • Sensory or motor disturbance
  • Seizures
  • Ptosis
  • Bruits
  • Dysphasia
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19
Q

What features may be found on examination in subarachnoid haemorrhage?

A
  • Depressed level of consciousness
  • Neck stiffness
  • Intraocular haemorrhages
  • Isolated pupillary dilation with loss of light reflex
  • Focal neurological signs
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20
Q

What percentage of patients will have depressed level of consciousness in subarachnoid haemorrhage?

A

66%

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21
Q

What percentage of patients will have intraocular haemorrhages in subarachnoid haemorrhage?

A

15%

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22
Q

Why do patients with subarachnoid haemorrhage have neck stiffness?

A

Due to meningeal irritation because of blood in the CSF

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23
Q

What investigations may be useful in subarachnoid haemorrhage?

A
  • CT scan without contrast
  • Angiography
  • Lumbar puncture
  • ECG
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24
Q

What is a CT scan useful for in subarachnoid haemorrhage?

A

First line investigation - correctly identifies 95-98% of cases

25
Q

What will a CT scan show in subarachnoid haemorrhage?

A

Hyperdense appearance of blood in basal cisterns

26
Q

What is angiography useful for in subarachnoid haemorrhage?

A

Confirming the origin of the SAH

27
Q

Which types of angiography are useful for identifying anuerysms as cause of subarachnoid haemorrhage?

A
  • Cerebral angiography

- CT angiography

28
Q

What is cerebral angiography?

A

Injecting radiocontrast through a catheter to the brain arteries

29
Q

What can also be done using cerebral angiography?

A

Coiling of the aneurysm

30
Q

What is CT angiography?

A

Visualising blood vessels with radiocontrast on CT scan

31
Q

When is a LP useful in subarachnoid haemorrhage?

A

If CT scan is negative but history is suggestive and it is safe to do an LP

32
Q

What can an ECG show in subarachnoid haemorrhage?

A
  • QT prolongation
  • Q waves
  • Dysrhythmias
  • ST elevation
33
Q

What is it important not to mistake a subarachnoid haemorrhage for when looking at an ECG?

A

Acute MI

34
Q

What are the differentials of subarachnoid haemorrhage?

A
  • Other causes of headache
  • Stroke
  • Meningitis
  • Trauma
  • Cerebral venous sinus thrombosis
  • Cervical or carotid dissection
  • Hypertensive emergency
35
Q

What is the aim of initial management in subarachnoid haemorrhage?

A

Prevent further bleeding and reduce the rate of complications

36
Q

What is usually the initial step in managing subarachnoid haemorrhage?

A

Occlude the aneurysm to prevent bleeding

37
Q

What is the preferred method for aneurysm occlusion in subarachnoid haemorrhage?

A

Endovascular obliteration by coiling

38
Q

What do some patients require to occlude the aneurysm in subarachnoid haemorrhage?

A

Direct neurosurgical clipping

39
Q

What is another immediate risk of subarachnoid haemorrhage?

A

Delayed cerebral ischaemia due to vasospasm

40
Q

How is the risk of delayed cerebral ischaemia reduced in subarachnoid haemorrhage?

A
  • Oral nimodipine (60mg/4 hours)

- Maintaining circulatory volume

41
Q

What should every patient who has had a subarachnoid haemorrhage receive?

A

Specialist referral for investigation and definitive treatment

42
Q

What supportive therapy may be needed for conscious patients with subarachnoid haemorrhage?

A

Analgesia and antiemetics

43
Q

What supportive therapy may be needed for patients with reduced consciousness due to subarachnoid haemorrhage?

A

Intubation and ventilation

44
Q

What should all surviving subarachnoid haemorrhage patients be advised of?

A

Secondary prevention

45
Q

What are the most important secondary prevention measures in subarachnoid haemorrhage?

A

Treatment of hypertension and stopping smoking

46
Q

What will a patient with residual impairment post-subarachnoid haemorrhage require?

A

Referral to rehabilitation services

47
Q

What is the overall death rate of subarachnoid haemorrhage?

A

~50%

48
Q

What proportion of subarachnoid haemorrhage survivors remain dependent?

A

1/3

49
Q

What are the short term complications of subarachnoid haemorrhage?

A
  • Rebleeding
  • Delayed cerebral ischaemia
  • Hydrocephalus
50
Q

When is the risk of rebleeding highest?

A

In the first few days

51
Q

What does rebleeding carry a high risk of?

A

Permanent disability and death

52
Q

What happens in delayed cerebral ischaemia?

A

The blood vessel goes into spasm causing narrowing and dangerously low blood supply to the brain

53
Q

What can occur as a result of delayed cerebral ischaemia?

A

Brain damage

54
Q

What are the common symptoms of subarachnoid haemorrhage?

A

Increasing drowsiness with or without other stroke-like symptoms

55
Q

What are the symptoms of hydrocephalus?

A
  • Headache
  • Vomiting
  • Blurred vision
  • Difficulty walking
56
Q

What are the potential long term complications of subarachnoid haemorrhage?

A
  • Epilepsy
  • Cognitive dysfunction
  • Changes in mood
57
Q

What cognitive dysfunction can occur as a result of subarachnoid haemorrhage?

A
  • Memory problems
  • Planning problems
  • Concentration problems
58
Q

What mood changes can occur after a subarachnoid haemorrhage?

A
  • Depression
  • Anxiety
  • PTSD

4/3: Elderly/Neuro Y3/4 - Neuro and Stroke [12] (33 decks)

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