Brain haemorrhage Flashcards
Define when you would do a CT
Children are at a high risk for contusion and intracerebral haemorrhage following head injury, but they are also at an increased risk from CT radiation to the head causing cancer so clear guidelines depict CT scanning in children:
Head injury and ≥2 of the following -> CT scan <1 hour; if just 1 of the following -> observe for a minimum of 4 hours
- LOC >5 minutes
- Abnormal drowsiness
- ≥3 episodes of vomiting
- Dangerous mechanism / high-impact injury
- Amnesia >5 minutes (anterograde and retrograde)
Head injury and 1 or more of the following -> CT scan <1 hour
- NAI
- Post-traumatic seizure (no epilepsy history)
- GCS <14
- 2 hours after injury GCS <15
- Suspected open/depressed skull fracture / tense fontanelle
- Basal skull fracture signs (i.e. racoon eyes, battle sign, rhinorrhoea)
- Focal neurological deficit
Child <1yr and bruise, swelling or laceration >5cm on head
Extradural Haemorrhage
- Usually following direct trauma
- Can be associated with skull fracture – tear of middle meningeal artery
- Battle sign
- Racoon eyes
Signs & symptoms:
* Lucid interval followed by deterioration of consciousness and seizures
* Potential focal neurological signs
- Dilatation of ipsilateral pupil
- Paresis of contralateral limb
- Anaemia
- Shock
Investigations -> CT-head
Management:
* Fluid resuscitation -> correct hypovolemia
* Evacuation of haematoma and arrest bleeding (neurosurgery)
Subdural Haemorrhage
Results from tear of vein as they cross the subdural space
* Gradually decreasing GCS (no lucid interval, just gradually decreasing)
Characteristically NAI with shaking of a baby or direct trauma
Potential retinal haemorrhages
NOTE: subdural haematomas may occur in those with ventriculoperitoneal shunts
Gradually decreasing GCS (no lucid interval, just gradually decreasing)=
INVESTIGATIONS
* CT scan
MANAGEMENT
* Burr hole craniotomy
* Prophylactic antiepileptics
* Correction of coagulopathy
* Follow up imaging
Subarachnoid haemorrhage
Rare in children; cause often aneurysm or Arterio Venus Malformation
Signs & symptoms -> acute onset head pain, neck stiffness, fever ± seizures or coma, vomiting, confusion, LOS
Investigations -> CT (blood in CSF) or MR angiography, avoid LP (due to risk of increased ICP)
Management -> neurosurgery or interventional radiology
Interventricular haemorrhage
Definition: Haemorrhage
Site of origin of bleeding is generally in the small blood vessels in the germinal matrix
IVH causes
Haemorrhages occur in 20% of VLBW infants
- Haemorrhages usually occur in the germinal matrix, above the caudate nucleus (which contains a fragile network of blood vessels)
Most IVHs occur within the first 72 hours of life
They are more common:
* Following perinatal asphyxia
* In infants with severe RDS
IVH risk factors
Prematurity (< 32 weeks)
Low birth weight
RDS
Hypoxia
Sepsis
Low/high BP
Hypovolaemia
Pneumothorax
IVH grades
Grade I: Haemorrhage occurs into the germinal matrix and contained within this layer (and up to 10% of the ventricle).
* NOTE: the bottom of the ventricle is the choroid plexus which lines the surface with CSF and bleeding occurs into this layer.
* There is usually no significant long-term adverse outcome
Grade II: Haemorrhage occurs outside of this germinal matrix layer and into the ventricle
- Fills 10-50% and NO dilation
Grade III: Haemorrhage fills > 50% of the ventricle OR there is < 50% filling but dilation of the ventricle
- Strong likelihood of physical impairment, depends on where the pathology is and if there is hydrocephalus present
**Grade IV: **haemorrhage involves parenchyma (unilateral periventricular haemorrhagic infarction), either as an extension from the ventricle or germinal matrix
- Almost always associated with poor prognosis
- There is also a criteria for limitation of care in these patients.
- This usually results in hemiplegia
Complication: This may impair the drainage and reabsorption of CSF, thus allowing CSF to build up under pressure. This dilation may resolve spontaneously or progress to hydrocephalus – this is known as post-haemorrhagic ventricular dilation/ post-haemorrhagic hydrocephalus
This may spontaneously arrest with no need for intervention, rapidly progress or slowly progress persistently
IVH presentation
Most cases present around 3rd day of life, can be delayed after the first week.
Silent presentation- detected on routine USS
Saltatory or stuttering course, evolving over hours to several days
* Altered level of consciousness - sleepiness and lethargy
* Hypotonia
* Decreased spontaneous and elicited movements
* Subtle changes in eye position and movement
Catastrophic deterioration
* Irregular respiration, hyperventilation, apnoea
* Decerebrate posturing
* Generalised seizures (tonic)
* Flaccid weakness
* Cranial nerve abnormalities, including pupils fixed to light
Raised ICP
* Bulging/ tense anterior fontanelle
* Head circumference increases rapidly
* Cranial sutures separate
IVH investigations
Bloods and blood gas
Cranial USS- can also detect severity
- Periventricular white matter brain injury may occur following ischaemia or inflammation, even in the absence of haemorrhage.
- There may be an echo-dense area or ‘flare’ within the brain parenchyma.
- This may resolve within a week (in which case, the risk of cerebral palsy is NOT increased)
- If cystic lesions become visible on USS 2-4 weeks later, there is definite loss of white matter
IVH management plan
Supportive
* Maintenance of arterial perfusion
* Adequate oxygen and ventilation
* Fluid, metabolic and nutritional support
Seizure management
Serial monitoring to detect for post-haemorrhagic ventricular dilation
For PHVD:
* Serial LPs and/or ventricular tap to drain CSF if hydrocephalus
* Permanent ventriculoperitoneal shunt if persisting
IVH complications/ prognosis
Complications
Post-haemorrhagic ventricular dilation/ hydrocephalus
Bilateral multiple cysts (periventricular leukomalacia(PVL))- it is associated with a risk of spastic diplegia and cognitive impairment
Prognosis
Antenatal glucocorticoids prior to preterm delivery is associated with a REDUCTION in incidence and severity of RDS and therefore IVH.
About 50% of infants with progressive PVHD have cerebral palsy
