Haemorrhagic stroke/intracranial haemorrhage

Question 1

How is intracerebral haemorrhage diagnosed ?

Answer 1

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

Question 2

What other investigations do you want to do for haemorrhagic stroke ?

Answer 2

• FBC
• Clotting tests, platelet function tests
• Intracerebral haemorrhage score
• Lumbar puncture for SAH required to exclude diagnosis even if CT neg I think
• etc

Question 3

Define haemorrhagic stroke ?

Answer 3

Haemorrhagic stroke is due to rupture of a cerebrospinal artery, resulting in either intraparenchymal (intracerebral), subarachnoid, or intraventricular haemorrhage (ICH).

Question 4

How is intracerebral/intraparenchymal haemorrhagic stroke categorised depending on the cause ?

Answer 4

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)

Question 5

What are the main symptoms of haemorrhagic stroke ?

Answer 5

• 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

Question 6

What are the specific signs/symptoms more suggestive of ICH?

Answer 6

• Headache
• Focal neurological deficit
• Decreased conscious level

Question 7

What are 2 of the characteristic HTN ICH ?

Answer 7

1. ‘Charcot- Bouchard’ microaneurysms arising on small perforating arteries
2. Basal ganglia haematoma

Question 8

What is the initial management for all haemorrhagic strokes and why ?

Answer 8

• 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.

Question 9

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)

Answer 9

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

Question 10

What is the management of non-cerebellar ICH where the patient is unstable ?

Answer 10

• 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

Question 11

What is a potential complication of ICH or subarachnoid haemorrhage and how is it treated ?

Answer 11

Hydrocephalus - can do a LP or external ventricular drain (EVD) acutely, if CSF flow not re-established then ventriculoperitoneal shunt required

Question 12

What is the management of cerebellar haemorrhage >3cm or patient is drowsy/unstable ?

Answer 12

Same normal management as all the others except yuo would do surgical management by removing the haematoma

Question 13

What are the risk factors for SAH?

Answer 13

• Fam history
• HTN
• Heavy alcohol consumption
• Connective tissue disease - autosomal dominant polycystic kidney disease (ADPKD), ehler danlos disease type IV, NF1

Question 14

What are the main causes of SAH?

Answer 14

• Spontaneous - usually due to a ruptured berry aneurysm (85%)
• AVM
• Trauma

Question 15

What is the key characteristic feature of SAH ?

Answer 15

Thunderclap headache

Question 16

What are the other signs/symptoms suggesting SAH?

Answer 16

• 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

Question 17

How is SAH diagnosed ?

Answer 17

• 1^st line = CT scan, which detects >90% within the first 48hrs
• 2^nd 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

Question 18

What investigation needs to be done for a confirmed spontaneous subarachnoid haemorrhage to determine the cause and ==> treatment of it ?

Answer 18

Digital Subtraction Angiography either CTA (CT angiography) or MRA (MRI angiogrpahy)

Helps determine if their is single or multiple aneurysms

Question 19

What is the management of subarachnoid haemorrhage (SAH)?

Answer 19

• 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

Question 20

What are the complications that can arise following a SAH ?

Answer 20

• 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

Question 21

What is the main cause of intraventicular haemorrhage ?

Answer 21

• 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

Question 22

What type of haemorrhage is shown in this pic and what are its characterisitic radiological findings ?

Answer 22

Intraventricular haemorrhage - characteristically see hyperdense material in the ventricles

(note it has a similar presentation to SAH for signs/symptoms)

Question 23

What are the characteristic radiological findings of the type of haemorrhage shown and obv what type of haemorrhage is shown?

Answer 23

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

Question 24

What type of haemorrhage is shown and what are its characterisitic radiological features ?

Answer 24

ICH - Hyperdensity in different areas of the brain parenchyma dependant on the subtype of intracerebral haemorrhage

Question 25

What is seen on lumbar puncture which suggests SAH ?

Answer 25

bloodstained or xanthochromic CSF