Bleeding in the brain

Question 1

What is an arteriovenous malformation (AVM)?

Answer 1

• complex tangle of arteries and veins connected with fistulas, creating a shunt (no capillary bed)
• common cause of haemorrhage in adults < 40

Question 2

Where do AVMs cause bleeding?

Answer 2

Most commonly intracerebral

Can be intraventricular or subarachnoid

Question 3

Which investigation is best for AVMs?

Answer 3

Catheter angiography

CT angiogram can be used in emergencies

Question 4

Where is the blood in a subarachnoid haemorrhage?

Answer 4

Subarachnoid space, between arachnoid membrane and pia

Question 5

What is the most common cause of a SAH?

Answer 5

Ruptured berry/saccular aneurysm

Question 6

Where do berry aneurysms most commonly arise?

Answer 6

Circle of Willis - anterior circulation (internal carotid territory) 90%
Posterior 10%

Question 7

Name 3 risk factors for berry aneurysms

Answer 7

POLYCYSTIC KIDNEY DISEASE
Hypertension
Smoking

Question 8

What are the clinical features of a SAH?

Answer 8

Sudden onset thunderclap headache (occipital)
Neck stiffness and photophobia
N&V

Question 9

How do you diagnose a SAH?

Answer 9

CT

Question 10

What should you do if CT is normal in a suspected SAH?

Answer 10

Lumbar puncture

–> xanthochromia (yellow discolouration) or blood stained CSF

Question 11

What are the complications of SAH?

Answer 11

Vasospasm: delayed neurological deficit, peak 3-14 days
- treat with nimodipine (prevent spasms) and BP control
Re-bleeding
Hydrocephalus
Seizures
Hyponatraemia

Question 12

Where does the bleeding occur in a subdural haemorrhage?

Answer 12

Between dura mater and arachnoid membrane

Question 13

Which vessels bleed to cause a subdural haemorrhage?

Answer 13

Bridging veins

Question 14

Which types of patients get subdural haemorrhage?

Answer 14

Elderly, alcoholic –> frequent falls
Anti-coagulated
Sign of NAI in babies

Question 15

Which investigation would you do for a subdural haemorrhage and what would it show?

Answer 15

CT –> crescent shaped haemorrhage

crosses suture lines but not midline

Question 16

What are the clinical features of a subdural haemorrhage?

Answer 16

Headache
Impaired consciousness + confusion
Focal neurological signs
Memory impairment

Question 17

What is a cavernous malformation?

Answer 17

Well circumscribed, benign vascular lesion (resembles a mulberry)

Question 18

How would you investigate a cavernous malformation?

Answer 18

MRI gold standard –> popcorn like appearance
CT if acute haemorrhage
Angiogram NOT helpful as low flow lesions, but can rule out other conditions

Question 19

Where is the blood in an extra/epidural haemorrhage?

Answer 19

Between the dura and bone

Question 20

Which vessels are the most common cause of bleeding in an extradural haemorrhage?

Answer 20

Middle meningeal artery

• anterior branch vulnerable as lies beneath pterion
• parietotemporal skull fracture

Question 21

What is the clinical presentation of an extradural haemorrhage?

Answer 21

Brief LOC followed by lucid interval –> deterioration

• headache, vomiting, contralateral hemiparesis
• ipsilateral pupillary dilatation (CN3)
• rapid decline as high pressure artery source (unlike subdural with low pressure veins)

Question 22

What would the CT show in an extradural haemorrhage?

Answer 22

Lens/lentil shaped haemorrhage

Mass effect + herniation (midline shift)