Haemorrhage

Question 1

Give 4 types of intracranial haemorrhage. What types of vessel and where do they occur?

Answer 1

Extradural - arterial bleed - between skill and parietal layer of dura matter.

Subdural - venous, bridging veins - between dura and arachnoid mater

Subarachnoid - arterial bleed - between pia an arachnoid mater

Intracerebral - bleeding within brain parenchyma itself

Question 2

What is the most frequent intracranial haemorrhage in young people? What does this result from? What is the presentation?

Answer 2

Extradural haemorrhage
o Typically results from contact sport or RTC
o They regain consciousness initially then deteriorate hours later (so can have okay GCS on presentation then suddenly decline)
o Doesn’t usually spread beyond suture lines because of dura adherence to sutures
o Associated with skull fractures – most commonly pterion and MMA

Question 3

Which haemorrhage is associated with skull fractures?

Answer 3

Extradural, most commonly pterion and MMA

Question 4

How do acute and chronic subdural haemorrhages differ on CT?

Answer 4

Chronic become dense and darker on CT due to degradation.

Question 5

What is the difference between an acute, sub-acute and chronic subdural haemorrhage?

Answer 5

Acute immediately after injury
Subacte 3-7 days
Chronic 2-3weeks after injury

Question 6

What often causes subarachnoid haemorrhages?

Answer 6

Berry aneurysms which occur at the bifurcations of major arteries of the circle of Willis here the pressure is highest.

Question 7

What is the presentation of subarachnoid haemorrhage?

Answer 7

Classic thunderclap headache - sudden worse headache

Can be similar to meningitis - neck stiffness, photophobia but no fever

Question 8

How does intra cerebral haemorrhage present?

Answer 8

May present similarly to subarachnoid haemorrhage - thunderclap headache, neck stiffness, photophobia
signs and symptoms correspond to area of brain affected like stroke

Question 9

What does fracture of pterion lead to?

Answer 9

Rupture of middle meningeal artery and extradural bleed

Question 10

Describe a extradural haemorrhage on CT.

Answer 10

Biconvex shape Bleed between the skull and periosteum (parietal layer of the dura mater)
Blood compresses brain tissue rather than peeling periosteum from bone.
Haemorrhage is limited by cranial sutures as the periosteum is continuous through them

Question 11

What is the typical presentation of an extradural/epidural haemorrhage?

Answer 11

Young person following trauma
Loses consciousness, then has a lucid interval with a headache, then begins to lose consciousness again.

Confusion vomiting seizures

Question 12

What is the typical presentation of a subdural haemorrhage?

Answer 12

Elderly person with a history of minor or forgotten head injury
Can cause increase in ICP

Question 13

What does a subdural haemorrhage look like on CT?

Answer 13

Crescent shaped haemorrhage, limited by dural reflections

Question 14

What typically causes subarachnoid haemorrhage? How does it present?

Answer 14

Due to rupture of berry aneurysm in circle of willis

Sudden onset thunderclap headache

Question 15

How can you diagnose subarachnoid haemorrhage? When is this contraindicated?

Answer 15

Lumbar puncture to show blood in subarachnoid space

Raised ICP - should not do LP due to risk of brain matter being compressed and pushed toward the spine

Question 16

What is diffuse axonal injury?

Answer 16

Acceleration and deceleration causes the brain to move in the skull and due to the differences in white and grey matter density, it causes shearing of axons at the junction between white and grey matter.

Question 17

How does diffuse axonal injury present? How is it diagnosed and managed?

Answer 17

Instant loss of consciousness
People remain in persistent vegetative state
Diagnosis by MRI
Management aims to prevent secondary damage due to oedema and hypoxia

Question 18

What are signs of skull fracture?

Answer 18

CSF rhinorrhoea - out of nose
CSF otorrhoea - out of ears if tympanic membrane ruptures
- confirm fluid is CSF - urine dip shows high glucose - test for beta-2-transferrin - halo ring sign on filter paper

Bruising - periorbital ecchymosis (Raccoon eyes) - behind ears - mastoid ecchymosis (Battle’s sign) - suggests fracture allowing blood to pool around eyes and mastoid process

Question 19

What are coup and contra coup injuries?

Answer 19

Coup injuries are at the site of impact
Contrecoup injuries are injuries when the force of the injury causes the brain to impact in the other side of the skull
They often occur together and can cause extradural haemorrhage.

Question 20

What are the two main MRI sequences? What is the difference?

Answer 20

T1 - shows fluid to have low signal, grey matter to have intermediate and white matter to have higher intenstiy.

T2 - shows fluid to have high signal intensity, grey matter to have intermediate, white matter to have low