Haemorrhage Flashcards
Intracerebral haemorrhage is bleeding into the brain parenchyma itself.
What does it look like on CT imaging?
- demonstrates hyper-dense (white) lesion
- +/- oedema
- +/- mass effect
- +/- ventricular extension
Subarachnoid haemorhage is caused by spontaneous arterial bleeding into the subarachnoid space.
What is the aetiology of this?
- commonly due to trauma
- but spontaneous SAH mostly caused by rupture of intracranial berry (saccular) aneurysm (75%)
- other causes: AV malformations, vasculitis, coagulopathy
What are clinical features of subarachnoid haemorrhage?
- CN III palsy → presence of a posterior communicating artery aneurysm compressing ipsilateral CNIII (pre-rupture)
- sudden severe “thunderclap” headache (occipital)
- nausea + vomiting
- transient loss of consciousness or seizure immediately
- signs of meningism 3-12hrs after:
- neck stiffness, photophobia
- positive Kernig’s sign
- focal neurological signs
- ocular haemorrhage +/- papilloedema
What investigations can be done for subarachnoid haemorrhage?
- urgent non-contrast CT head within 12hrs → will show hyperdense areas in basal cisterns, CoW, major fissures + sulci
- bloods → FBC, U+Es, clotting profile, troponin I
- ECG → 50% of pts have abnormal
- lumbar puncture → do if CT -ve - take 3 vials: shows xanthochromia, can check MC+S + protein too
- digital subtraction angiography (DSA) → accurate for visualising aneurysms + carried out once diagnosis of SAH made based on CT or LP
What is the treatment for subarachnoid haemorrhage?
- ABC, urgent ICU bed + neurosurg referral
- cardiopulmonary support → GCS assessed, need for ET intubation + mechanical ventilation assessed
- most intracranial aneurysms are now treated w/ a coil by interventional radiologists, but a minority require a craniotomy + clipping by a neurosurgeon
- NIMODIPINE (4hrly)→ ca-ch blocker for vasospasm prophylaxis, also reduce risk of poor outcome + secondary ischaemia after aneurysmal SAH
- laxatives to prevent straining + reducing risk of rebleeding
- analgesia → oxycodone (5-10mg orally every 4hrs PRN)
- treatment of hyponatraemia
A subdural haemorrhage is a collection of blood deep to the dura. The blood is not within the substance of the brain and is therefore called an extra-axial or extrinsic lesion. Can be unilateral or bilateral.
It is believed to be due to stretching + tearing of bridging cortical veins as they cross the subdural space to drain into an adjacent dural sinus.
An acute subdural is often due to high-impact trauma. What are clinical features of an acute subdural?
- headache → may be sign of raised ICP or meningeal irritation
- nausea/vomiting → raised ICP
- decreased GCS/LOC
- confusion
- loss of bladder + bowel continence
- localised weakness
- speech of vision changes
- otorrhoea/rhinorrhoea
CT imaging is the 1st line for subdural. What does an acute subdural haemorrhage look like on CT?
- typically crescentic (crescent moon-shaped, concave, banana-shaped)
- more extensive than extradural, with the internal margin parallelling the cortical margin of the adjacent brain.
- appear hyperdense (bright) in comparison to brain
- large acute subdural haematomas will push on brain (‘mass effect’) + cause midline shift or herniation
What is the management of subdural haemorrhage?
- check anti-coagulation - can this be reversed?
- observation, monitoring + follow-up imaging
- prophylactic antiepileptics
-
neurosurgery referral →
- ≥10mm size
- or midline shift >5mm
- or expansile
- or significant neurological dysfunction
- if <10mm + <5mm midline shift, evacuate if GCS dropping or asymmetric pupils
Elderly and alcoholic patients are particularly at risk of developing chronic subdural haemorrhages since they have brain atrophy and therefore fragile or taught bridging veins.
Presentation is typically a several week to month progressive history of either confusion, reduced consciousness or neurological deficit.
What will CT show for chronic subdural haematoma?
- crescenteric shape
- in contrast to acute, chronic are hypodense (dark) compared to substance of brain
What is the treatment for chronic subdural haemorrhage patients?
- antiepileptics
-
elective surgery if clinically indicated
- twist-drill craniotomy, burr hole irrigation, standard craniotomy, subdural-peritoneal shunting
Extradural haemorrhage is a collection of blood between the skull and dura. It is caused by low-impact trauma.
How does an extradural haemorrhage present?
- loss of consciousness → brief lucid interval → rapid decline in consciousness + focal neurological signs
- mass effect on brain will cause uncal herniation + fixed, dilated pupil due to CNIII compression
- usually associated w/ hx of head trauma + freq associated skull fracture
- source of bleeding usually arterial, most commonly from torn middle meningeal artery
What does extradural haemorrhage look like on CT?
Typically lentiform (lens-shaped, biconvex, lemon-shaped) and do not cross sutures as the periosteum crosses through the suture continuous with the outer periosteal layer.
What is the treatment for extradural haemorrhage?
- mannitol
- refer to neurosurgery for craniotomy, clot evacuation + ligation of artery
