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Neuro > Hemorrhage > Flashcards

Hemorrhage Flashcards

1
Q

What are the three types of hemorrhage?

A
  • Subdural
  • Subarachnoid
  • Epidural
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2
Q

What is an epidural hemorrhage often as a result of?

A

Most commonly due to a traumatic head injury

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3
Q

What ages is an epidural hemorrhage rare in?

A

<2 and >60

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4
Q

What is the characteristic history of an epidural hemorrhage?

A
  1. Head injury
  2. Brief post-traumatic loss of consciousness or initial drowsiness
  3. Lucid interval
  4. Period of time between traumatic brain injury and decrease in consciousness, whilst haematoma is still small and there is still some bleeding
  5. Can last several hours or even days
  6. Followed by altered consciousness, severe headache, nausea, vomiting, confusion
  7. Seizures due to rising ICP +/- hemiparesis (weakness of half the side of the body) with brisk reflexes (faster than usual)
  8. Rapid rise of ICP with brain compression
  9. Ipsilateral pupil dilates,
  10. Coma deepens
  11. Bilateral limb weakness develops and breathing becomes deep and irregular - signs of brainstem compression
  12. Decreased GCS and coning (brain herniates through the foramen magnum)
  13. Death due to respiratory arrest - if surgical intervention not done fast enough
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5
Q

What would you see on the CT head in an epidural hemorrhage?

A

Shows hyperdense haematoma that is biconvex and adjacent to the skull. Tough dural attachments keep the hematoma localised.

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6
Q

What would a skull x-ray show in an epidural heamorrhage?

A

May be normal or show fracture lines crossing the course of the middle meningeal artery.

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7
Q

What treatment would you use in an epidural stroke?

A
  • ABCDE emergency management - asses and stabilise patient
  • Give IV mannitol if increased ICP
  • Refer to neurosurgery
  • Clot evacuation +/- ligation of bleeding vessel
  • Maintain airway via intubation and ventilation in unconscious patient
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8
Q

What is a subarachnoid hemorrhage?

A

Spontaneous bleeding (not traumatic) into the subarachnoid space (between arachnoid layers of the meninges and pia mater)

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9
Q

What is the most common cause of a subarachnoid hemorrhage?

A

Rupture of a berry-aneurysm

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10
Q

Apart from rupture of a berry-aneurysm what is the other cause of a subarachnoid hemorrhage in 10% of cases?

A

Atriovenous malformation (AVM)

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11
Q

What are the risk factors for a subarachnoid hemorrhage?

A
  • Hypertension
  • Known aneurysm
  • Family history
  • Disease that predispose to aneurysm:
  • Polycystic kidney disease
  • Ehlers Danlos syndrome (hypermobile joints with increased skin elasticity)
  • Coarctation of aorta
  • Smoking
  • Bleeding disorders
  • Postmenopausal decreased oestrogen
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12
Q

What is the characteristic presentation of a subarachnoid hemorrhage?

A

Sudden onset “thunderclap” headache

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13
Q

What two tests can you perform to test for subarachnoid hemorrhage?

A
  1. Kernig’s sign (unable to extend patients legs at the knee when the thigh is flexed)
  2. Brudzinski’s sign (when patients neck is flexed by doctors, patient will flex their hips and knee)
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14
Q

What symptoms are present in a subarachnoid hemorrhage other than the thunder clap headache?

A
  • Vomiting
  • Collapse
  • Seizures
  • Comas / drowsiness (may last for days)
  • Depressed level of consciousness
  • Neck stiffness
  • Retinal and vitreous bleeds
  • Papilloedema - dilated optic disc
  • Vision loss or diplopia (double vision)
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15
Q

What investigations would you do if you suspect a subarachnoid hemorrhage?

A
  • ABG (to exclude hypoxia)
  • Head CT - GOLD standard diagnostic (seen as star shaped lesions due to blood filling in gyro patterns around the brain and ventricles)
  • CT angiography if aneurysm confirmed to see extent
  • Lumbar puncture (If CT normal but SAH still suspected
    Only 12 hours after haemorrhage
  • CSF in SAH is uniformly bloody early on and becomes xanthochromic (yellow) after several hours due to breakdown products of Hb (bilirubin)
    Xanthochromia presence CONFIRMS SAH
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16
Q

What is the treatment for subarachnoid hemorrhage?

A
  • Maintain cerebral perfusion (IV fuids)
  • Ca2 blocker (reduce vasospasm)
  • Endovascular coiling
  • Surgery - intracranial stents and balloon remodelling for wide necked aneurysms
17
Q

What is a subdural hemorrhage?

A

Hemorrhage caused by the accumulation of blood in the subdural space - between DURA and ARACHNOID

18
Q

What types of vessels like in the subdural space?

A

Bridging veins cross the subdural space

19
Q

How does a subdural hematoma usually start?

A

Trauma either due to deceleration due to violent injury or due to dural metastases results in bleeding from bridging veins between the cortex and venous sinuses

20
Q

What is a result of the bridging veins bleeding in a subdural hematoma?

A

This forms the haematoma (solid swelling of clotted blood) between the dura and arachnoid - this reduces pressure and bleeding stops

21
Q

What can happen days/weeks later after the haematoma has formed?

A

The haematoma starts to autolyse due to the massive increase in oncotic and osmotic pressure thus water is sucked into the haematoma resulting in the haematoma enlarging which then results in a gradual rise in intracranial pressure (ICP) over many weeks.

22
Q

What can be the result of clot formation in a subdural haematoma?

A

Shifting midline structures away from the side of the clot and if untreated leads to eventual tectorial herniation and coning (brain herniates through foramen magnum - causes significant damage)

23
Q

Aside from trauma, what are some other risk factors for subdural haematoma?

A
  • Alcoholism (caused cerebral atrophy)
  • Anticoagulation
  • Physical abuse of infant
24
Q

What is the key presentation in subdural haematoma?

A

Interval between injury and symptoms can be days to weeks or months.

25
Q

Apart from in interval between injury and symptoms how does a subdural haematoma present?

A
  • Sleepiness
  • Headache
  • Personality change
  • Unsteadiness
  • Signs of raised ICP eg headache, vomiting, nausea, seizure and raised BP
  • Focal neuropathy eg hemiparesis or sensory loss
  • Occur late and often long after injury, mean time = 63 days
  • Seizures occasionally
26
Q

What would you see on a CT scan in a subdural haematoma?

A

Diffuse spreading, hyperdense CRESCENT SHAPED collection of blood over 1 hemisphere
Sickle / crescent shape differentiates subdural blood from extradural haemorrhage
As the clot ages and protein degradation occurs it becomes isodense (same colour as brain tissue) and eventually becomes hypodense
Shifting of midline structures seen

27
Q

What would you look for on an MRI head in a subdural haematoma?

A

Subacute haematomas and smaller haematomas

28
Q

How would you manage a subdural haematoma?

A
  • Assess and manage ABCs, prioritise head CT
  • Stabilise patient
  • Refer to neurosurgeons:
  • Irrigation / evacuation via burr twist drill and burr hole craniotomy
  • Address cause of trauma eg fall due to cataract or arrhythmia or abuse
  • IV mannitol to reduce ICP (osmotic laxative)

Neuro (17 decks)

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