Brain Bleeds

Question 1

Describe features of an extradural haematoma

Answer 1

Almost always caused by trauma and is often collected at the pterion where the middle meningeal artery lies.
Classically presents with lucid interval.
Imaging shows biconvex, hyperdense collection, limited by suture lines.
Treatment - supportive if no neuro deficit otherwise craniotomy and evacuation of haematoma

Question 2

What are the clinical features of subdural haemorrhages?

Answer 2

Neurological symptoms - Fluctuating levels of consciousness, focal deficits, headaches, seizures.
Papilloedema,
Gait abnormalities,
Hemiparesis
Memory loss (especially in chronic),
Personality change,
Cognitive impairment,
N+V,
Drowsiness

Question 3

Cause and treatment of an acute subdural haematoma?

Answer 3

Most commonly caused by head trauma.
CT shows crescentic hyperdense collection, not limited by suture lines.
Small bleeds can be managed conservatively. Larger bleeds may need decompressive craniectomy.

Question 4

Cause and treatment of chronic subdural haematoma?

Answer 4

Rupture of bridging veins - Elderly and alcoholics particularly at risk.
Typically presents with several week to month history of confusion, reduced consciousness.
CT shows HYPOdense collection.
If small and no neuro deficit then manage conservatively otherwise decompression with burr holes may be required.

Question 5

Causes of a subarachnoid haemorrhage?

Answer 5

Traumatic
Spontanous - intracranial aneurysms, AV malformation, pituitary apoplexy, infective (mycotic) aneurysms

Question 6

What is the presentation of a subarachnoid hae

Answer 6

Sudden onset, severe, occipital headache
nausea and vomiting
meningism (photophobia, neck stiffness)
coma
seizures
ECG changes including ST elevation may be seen.

Question 7

Ix for suspected subarach haemorrhage

Answer 7

First line - non contrast head CT. If done within 6hr and negative then consider alternative dx. If done after 6hr then wait 12hr from onset of symptoms to do LP - look for xanthochromia.
Then urgent referral to neurosurgery

Question 8

Ix for confirmed subarach haemorrhage?

Answer 8

CT intracranial angiogram +/- digital subtraction angiogram.

Question 9

What is the management of a subarach haemorrhage?

Answer 9

Supportive - bed rest, analgesia, VTE prophylaxis,
Prevention of vasospasm with nimodipine.
Majority of aneurysms required coiling with minority needing craniotomy and clipping.

Question 10

Complications of a SAH

Answer 10

Re-bleeding.
Hydrocephalus - temporarily treated with external ventricular drain.
Vasospasm - ensure euvolaemia.
Hyponatraemia - due to SIADH
Seizures

Question 11

Important predictive factors for SAH

Answer 11

Conscious level on admission,
Age,
Amount of blood on CT.