Haemorrhagic stroke

Question 1

Define stroke

Answer 1

Stroke describes neurological deficit lasting longer than 24 hours due to vascular compromise

Question 2

Sub divisions of haemorrhagic stroke

Answer 2

• primary intracerebral - bleeding within brain parenchyma
• subarachnoid- bleeding into subarachnoid space
• intraventricular - bleeding within the ventricles ; prematurity is a very strong risk factor

Question 3

What are haemorrhagic strokes caused by

Answer 3

Ruptured blood vessel leading to reduced blood flow

Question 4

Definition of intracerebral haemorrhage

Answer 4

Sudden bleeding into brain tissue due to rupture of blood vessels

Question 5

intracerebral stroke is caused by?

Answer 5

• Trauma
• Arteriovenous malformation
• Cerebral amyloid
• Hypertension

Question 6

Subarachnoid haemorrhage is caused by

Answer 6

• Trauma
• Berry aneurysm
• Arteriovenous malformation

Question 7

what is SAH

Answer 7

intracranial haemorrhage characterised by blood within the subarachnoid space such as sylvian fissures and basal cisterns

Question 8

most common locations for berry aneurysms

Answer 8

• junction between the anterior communicating and anterior cerebral arteries

Question 9

two biggest risk factor for SAH

Answer 9

HT and SMOKING

Question 10

Other risk factors for SAH

Answer 10

-AGE
- fx
- pkd
-alcohol

Question 11

what layers of the brain are classed as leptominenges

Answer 11

arachnoid
pia

Question 12

what do SAH lead to

Answer 12

pool of blood under the arachnoid mater that increase intracranial pressure and prevents more blood from flowing into the brain

Question 13

symptoms of a SAH

Answer 13

• Headache
• meningism
• N/V
• confusion and coma

Question 14

What type of headache would occur in SAH

Answer 14

• severe sudden onset
• occipital
• ‘thunderclap’ headache

Question 15

signs of a SAH

Answer 15

3rd nerve palsy
- An aneurysm arising from the posterior communicating artery will press on the 3rd nerve, causing a palsy with afixed dilated pupil

6th nerve palsy
- a non specific sign which indicates raised intracranial pressure

• reduced GCS

Question 16

1st investigations for SAH

Answer 16

• urgent non-contrast CT head
• ECG
• FBC
• serum electrolytes
• clotting profile

Question 17

Investigations to consider in SAH

Answer 17

• lumbar puncture
• ct angiogram

Question 18

What would ct scan exhibit for SAH

Answer 18

• star shape

Question 19

Management for SAH

Answer 19

• Nimodipine 60mg 4 hourly upon diagnosis, to prevent vasospasm
• intervention =first-line is endovascular coiling of the aneurysm by an interventional radiologist; second-line is surgical clipping via craniotomy

Question 20

if there are features of raised intracranial pressure then what is the management

Answer 20

• consider intubation with hyperventilation, head elevation (30°) and IV mannitol

Question 21

conservative management of SAH

Answer 21

• Bed rest
  -Antitussive agent and stool softeners: prevents straining and therefore reduce the risk of rebleeding

Question 22

complications of SAH

Answer 22

• rebleeding
• vasospasm
• Triple H - hyperventilation, hypervolaemia, hemodilution

Question 23

What is triple H

Answer 23

• hypertension
• hypervolaemia
• haemodilution

Question 24

prognosis of SAH

Answer 24

At 6 months 25% dead 50% disabled

Question 25

What is a primary intracerebral haemorrhage

Answer 25

bleeding within the cerebrum

Question 26

What is a primary intracerebral haemorrhage?

Answer 26

Leakage of blood directly into brain tissue due to: - Hypertension- weakens deep perforating blood vessels - Amyloidosis - Arteriovenous malformation - Aneurysm rupture

Question 27

causes of intracerebral H

Answer 27

- Hypertension- weakens deep perforating blood vessels - Amyloidosis - Arteriovenous malformation - Aneurysm rupture

Question 28

What is a secondary intracerebral hemorrhage?

Answer 28

due to trauma, warfarin or bleeding into a tumour are not classed as “strokes” but can cause similar symptoms

Question 29

difference between an intraparenchymal haemorrhage and an intraventricular haemorrhage

Answer 29

just the brain tissue is called an intraparenchymal haemorrhage, whereas if the blood extends into the ventricles of the brain which store cerebrospinal fluid, it’s called an intraventricular haemorrhage.

Question 30

What is amyloidosis

Answer 30

dysfunctional brain proteins

Question 31

A rupture can occur due to

Answer 31

- HTN - AV malformations - vasculitis - vascular tumors

Question 32

pathophysiology of an ICH

Answer 32

blood starts to spew out from a damaged blood vessel creating a pool of blood which increases pressure in the skull and puts direct pressure on nearby tissue cells and blood vessels.

Question 33

clinical manifestations for ICH

Answer 33

- **Headache** - **Weakness** - **Seizures** - **Vomiting** - **Reduced consciousness**

Question 34

Management for ICH

Answer 34

- **Consider intubation, ventilation and ICU care if they have reduced consciousness** - **Correct any clotting abnormality** - **Correct severe hypertension but avoid hypotension**

Question 35

what drugs can relieve intracranial pressure

Answer 35

mannitol

Question 36

What is a subdural haemorrhage

Answer 36

Bleeding below the dura mater due to a rupture of a bridging vein

Question 37

location for subdural haemorrhage

Answer 37

between the dura and arachnoid

Question 38

what would ct show for subdural

Answer 38

cresent/ banana shape and are not limited by the cranial sutures

Question 39

RFs for subdural haemorrhage

Answer 39

Recent trauma - falls advanced age anticoagulant use coagulopathy

Question 40

epidemiology of SBH

Answer 40

- elderly - alcoholics

Question 41

Rupture of bridging veins, usually caused by:

Answer 41

- brain atrophy , age - alcohol abuse - walls of the veins will thin out - trauma/ injury

Question 42

timespan for subdural haemotoma

Answer 42

acute - symptoms in 2 days subacute- 3-14 days chronic- over 15

Question 43

Haematoma and haemorrhage?

Answer 43

When there is active bleeding, it’s called a haemorrhage, and the collection of blood that results is called a haematoma.

Question 44

Clinical presentation of subdural haematoma

Answer 44

- reduced gcs - headache - vomiting - seizures - unsteadiness

Question 45

investigations for SBH

Answer 45

- immediate ct head scan to establish diagnosis

Question 46

signs of Intercranial pressure

Answer 46

Cushings triad- bradycardia, irregular respirations and a widened pulse pressure

Question 47

Tx for SBH

Answer 47

- SURGERY - burrhole and craniotomy( for large) - IV mannitol to decrease ICP

Question 48

Define Extradural (Epidural) Haemorrhage

Answer 48

bleeding above the dura mater

Question 49

Who is mostly affected by Extradural (Epidural) Haemorrhage

Answer 49

young adults 20-30

Question 50

What is Extradural Haemorrhage usually caused by

Answer 50

trauma to middle meningeal artery due to damage to lateral pterygoid bone

Question 51

Main risk factor for Extradural Haemorrhage

Answer 51

HEAD INJURY

Question 52

Where do the frontal, parietal, temporal and sphenoid bones join

Answer 52

pterion

Question 53

how does Extradural Haemorrhage present

Answer 53

- Initial event - decrease gcs - ICP signs elevated - death from resp arrest LUCID STAGE ' I FEEL FINE' Rapid deterioration due to increase in ICP

Question 54

Why would resp arrest occur in EH

Answer 54

Tonsillar herniation + caving of brain due to untreated ICP

Question 55

What is the shape of a lesion for Extradural Haemorrhage

Answer 55

lemon shaped

Question 56

management of Extradural Haemorrhage

Answer 56

- urgent surgery - mannitol IV

Question 57

What is the glasgow coma scale based on

Answer 57

It is scored based on  eyes,  verbal  response and  motor  response.

Question 58

When would you consider securing an airway ( GCS)

Answer 58

- when someone has a score of 8/15

Question 59

describe the GCS

Answer 59

- out of 15 , minimum score is 3/15 eyes out of 4 verbal out of 5 motor out of 6 15= normal 8= comatose 3= unresponsive

Question 60

treatment decisions for hyperacute stroke?

Answer 60

Is the presentation compatible with stroke ? Is it a bleed or an infarct? Is this a case for thrombolysis or thrombectomy? What are the benefits? What are the risks ? How can we prevent stroke complications?