Haemorrhagic stroke/intracranial haemorrhage Flashcards
How is intracerebral haemorrhage diagnosed ?
The exact same as ischaemic - by CT +/- CT/MRI angiography if you are looking for an underlying cause of the haemorrhage e.g. a haemorrhagic stroke in someone <45 you might be thinking more secondary cause e.g. AVM
What other investigations do you want to do for haemorrhagic stroke ?
- FBC
- Clotting tests, platelet function tests
- Intracerebral haemorrhage score
- Lumbar puncture for SAH required to exclude diagnosis even if CT neg I think
- etc
Define haemorrhagic stroke ?
Haemorrhagic stroke is due to rupture of a cerebrospinal artery, resulting in either intraparenchymal (intracerebral), subarachnoid, or intraventricular haemorrhage (ICH).
How is intracerebral/intraparenchymal haemorrhagic stroke categorised depending on the cause ?
Into primary or secondary
Primary ICH is when there is an absence of any underlying AVM or coagulopathy =, HTN arteriosclerosis and amyloid angiopathy are the 2 main causes of primary haemorrhagic
Secondary = mainly caused by AVM’s and sometimes coagulopathy either congenital or aquired (medications)
What are the main symptoms of haemorrhagic stroke ?
- Neck stiffness
- Visual changes
- Photophobia
- Focal neurological deficit depending on brain area affected - sensory loss and weakness
- Headache, nausea and vomiting
- Loss of conciousness
- Aphasia
- Ataxia, dysathria (signs more suggestive of a cerebellar haemorrhage)
- Increased BP
What are the specific signs/symptoms more suggestive of ICH?
- Headache
- Focal neurological deficit
- Decreased conscious level
What are 2 of the characteristic HTN ICH ?
- ‘Charcot- Bouchard’ microaneurysms arising on small perforating arteries
- Basal ganglia haematoma
What is the initial management for all haemorrhagic strokes and why ?
- Admitted to a neuroscience ICU due to the following potential risks or requirements:
- Hourly neurological observations
- Intubation with mechanical ventilation
- Depressed consciousness
- High risk for haematoma expansion
- BP monitoring or control with continuous infusions
- Need for external ventriculostomy catheter, intracranial pressure (ICP) monitor, or surgical intervention.
What is the management of ICH non cerebellar - stable and alert haemorrhages, and what is the management of cerebellar haemorrhage where patient is stable and alert and haemorrhage is <3cm? (hint both exact same)
Already been admitted to NICU
- Supportive care
- BP control (if BP >180) - 1st line = labetalol, 2nd line = nicardipine
- DVT prophylaxis with pneumatic compression devices and early mobilisation
- Correction of coaguloapthy if required
What is the management of non-cerebellar ICH where the patient is unstable ?
- Supportive care
- BP control (if BP>180)
- Surgery - remove clot (by clot I mean the bleed that has formed) if possible
- ICP management if needed - head to 30degrees, mannitol give 1st line, 2nd line = hypertonic saline
What is a potential complication of ICH or subarachnoid haemorrhage and how is it treated ?
Hydrocephalus - can do a LP or external ventricular drain (EVD) acutely, if CSF flow not re-established then ventriculoperitoneal shunt required
What is the management of cerebellar haemorrhage >3cm or patient is drowsy/unstable ?
Same normal management as all the others except yuo would do surgical management by removing the haematoma
What are the risk factors for SAH?
- Fam history
- HTN
- Heavy alcohol consumption
- Connective tissue disease - autosomal dominant polycystic kidney disease (ADPKD), ehler danlos disease type IV, NF1
What are the main causes of SAH?
- Spontaneous - usually due to a ruptured berry aneurysm (85%)
- AVM
- Trauma
What is the key characteristic feature of SAH ?
Thunderclap headache
What are the other signs/symptoms suggesting SAH?
- Neck stiffness
- Photophobia
- Decreased conscious level, almost half collapse and loose conciousness
- Focal neurological deficit (dysphasia, hemiparesis, IIIrd n. palsy)
- Fundoscopy - retinal or vitreous haemorrhage
How is SAH diagnosed ?
- 1st line = CT scan, which detects >90% within the first 48hrs
- 2nd line = LP if CT scan negative and no contraindication to LP > 12hr after onset of headache. Finding xanthochromia in the CSF is diagnostic of SAH. Note that the CSF becomes xanthochromic (yellow) between 6-48hr, initially before this the CSF may just be uniformly blood
What investigation needs to be done for a confirmed spontaneous subarachnoid haemorrhage to determine the cause and ==> treatment of it ?
Digital Subtraction Angiography either CTA (CT angiography) or MRA (MRI angiogrpahy)
Helps determine if their is single or multiple aneurysms
What is the management of subarachnoid haemorrhage (SAH)?
- Admitt to NICU for supportive care
- Surgery - surgical clipping or endovascular coil embolisation (possibly coil is better but up for discussion) +/- craniotomy
- CCB - nimodipine give to reduce chances of delayed ischaemia by reducing vasospasm
- Stool/softner - docusate, senna etc
- seizure prohylaxis
- Hyponatraemia may arise and treated with fludrocortisone, do not fluid restrict then and supplement sodium intake
What are the complications that can arise following a SAH ?
- Re-bleeding - there is a 50% risk in up to 6 months following, this is the main cause of death, it usually presents in the first few days
- Delayed ischaemic deficit - occurs between 3-12 days after SAH
- Hydrocephalus - may present as increasing headache or altered consciousness
- Hyponatraemia
- Seizures
What is the main cause of intraventicular haemorrhage ?
- Usually due to a large ICH or SAH with secondary extension to the ventricles
- Note you can get primary intraventricular haemorrhage but this is much less common
What type of haemorrhage is shown in this pic and what are its characterisitic radiological findings ?
Intraventricular haemorrhage - characteristically see hyperdense material in the ventricles
(note it has a similar presentation to SAH for signs/symptoms)
What are the characteristic radiological findings of the type of haemorrhage shown and obv what type of haemorrhage is shown?
SAH - hyerattenuating material is seen filling the subarachnoid sapce - often occurs around the circle of willis (majority of berry aneurysms occur here) or slyvian fissure
What type of haemorrhage is shown and what are its characterisitic radiological features ?
ICH - Hyperdensity in different areas of the brain parenchyma dependant on the subtype of intracerebral haemorrhage
What is seen on lumbar puncture which suggests SAH ?
bloodstained or xanthochromic CSF
