Brain bleeds

Question 1

What are the causes of subarachnoid haemorrhage (SAH)?

Answer 1

Berry anaeurysm rupture
Arterio-venour malformations
Encephalitis, vasculitis, tumour

Question 2

What are the symptoms of SAH?

Answer 2

Sudden onset headache

• thunderclap
• occipital

Vomiting, collapse, seizures, coma
Neck stiffness, kernig’s sign, retinal/subhyaloid/vitreous bleeds

Question 3

What are some risk factors for berry aneurysms?

Answer 3

Polycystic kidneys
EDS
Aortic coarcation

Question 4

What are the Ddx of SAH?

Answer 4

Meningitis, migraine, intracerebral bleed, cortical vein thrombosis, benign thunderclap

Question 5

What tests are done for SAH?

Answer 5

CT

LP - can be xanthochromic (yellow) from RBC breakdown

Question 6

How is SAH managed?

Answer 6

Monitoring CNS symptoms
Maintain cerebral perfusion with systolic BP <160
Nimodipine for 3 weeks (CCB)
Surgery - coiling/clipping

Question 7

What signs indicate an intracranial venous thrombus (IVT) of the sagittal sinus? (most common IVT)

Answer 7

Headache
Vomiting
Decreased vision
Papilloedema

Question 8

What signs indicate an IVT of the transverse sinus?

Answer 8

Headache 
Mastoid pain 
Focal CNS signs 
Seizures 
Papilloedema

Question 9

What signs indicate an IVT of the sigmoid sinus?

Answer 9

Cerebellar signs

Lower CN palsies

Question 10

What signs indicate an IVT if the inferior petrosal sinus?

Answer 10

V/VI CN palsy

Temporo and retro-orbital pain (Gradenigo’s syndrome)

Question 11

What signs indicate an IVT of the cavernous sinus?

Answer 11

Haedache 
Chemosis
Oedematous eyelids
Proptosis 
Fever
Painful ophthalmoplegia

Question 12

How does a cortical vein thrombosis present?

Answer 12

Stroke like - focal Sx
Onset over a few days
Sudden onset seizures and thunderclap headache

Question 13

How is an IVT managed?

Answer 13

Anticoagulate - LMWH/heparin
Then move to warfarin (INR 2-3)

Increased ICP -> herniation (main cause of death)
- may need a decompressive hemicraniectomy

Question 14

What are the symptoms of subdural haematoma?

Answer 14

Fluctuating consciousness
Physical/intellectual slowing
Sleepiness
Headache 
Personality change 
Unsteadiness 

Raised ICP, seizures, focal changes

Question 15

What does a CT show with a subdural haematoma?

Answer 15

Clot with midline shift

Crescent shaped collection of blood on one hemisphere (sickling indicates subdural rather than epidural)

Question 16

What is the management for a subdural haematoma?

Answer 16

Reverse any clotting abnormalities

Evacuate bleed if:

• clot > 10mm
• midline shift > 5mm

Question 17

What are the causes of an epidural hamatoma?

Answer 17

Trauma (over the pterion -> middle meningeal artery)

Question 18

What are the symptoms of an epidural haemorrhage?

Answer 18

Lucid interval (longer in older people - brain atrohpy)
Lowered GCS due to increased ICP
Worsening haedache, seizures, vomiting, confusion
UMN signs (hyperreflexia and upwards plantars)

Later developments:

• IL pupil dilation
• BL limb weakness
• Deep, irregular breathing
• Bradycardia
• HTN

Question 19

What does a CT show with an epidural haematoma?

Answer 19

Biconcave/lens shaoe blood - more rounded than subdural
May show some skull changes

DO NOT DO AN LP

Question 20

What is the management of an epidural haematoma?

Answer 20

Clot evacuation and ligation of bleeding vessel