Inter-cranial Haemorrhage

Question 1

Describe the clinical features of a sub arachnoid haemorrhage, and the most common cause?

Answer 1

A sudden onset severe headache (peak pain almost immediately).

Worst headache ever.

Usually in the occipital region.

May be focal neurology and meningisms*

Most commonly due to a ruptured berry aneurysm in teh circle of willis.

*Neck stiffness, photophobia and headache.

Question 2

Describe the vascular abnormalities which may predispose a patient developing a SAH?

Answer 2

Berry aneurysms: congenital weakness in the elastic lamina of aa, often develop at weak branch points in the circle of willis.

Arteriovenous malformations: Congenital defect in which there are abnormal anastomoses between the arterial and venous system without capillaries due to the abnormal pressure difference these are more likely to bleed.

Question 3

Which aa are most commonly have berry aneurysms?

Answer 3

40% occur at the internal carotid aa

30% occur at the anterior communicating aa

20% occur at the middle communicating aa

Question 4

Describe how a suspected SAH haemorrhage should be investigated?

Answer 4

CT scan without contrast as soon as possible, high sensitivity within the 1st 24hrs.

Lumbar puncture can be done if history is suggestive but CT scan is negative as it CT can give a false negative rate in 2% of cases.

Question 5

Describe the acute management of sub arachnoid haemorrhage?

Answer 5

Initial management of SAH aims to prevent further bleeding and reduce the risk of complications.

A-E assessment

Transfer to a specialist neurosurgical unit is needed. Patients will often need an ITU bed also and may be intubated and NG fed. Maintaining BP, electrolytes and BMs in a normal range is important.

Rebleed rates are high and devastating therefore neurosurgical intervention is needed either by:

• a craniotomy and clipping (placing clips around the neck of the aneurysm)

OR

• coiling performed through femoral catherisation (platinum coils obliterate the aneurysm by forming a coil inside)

4 wks bed rest, IV fluid, analgesia, stool softeners

Nimodopine (Ca antagonist) is used to prevent secondary vasopspasm

Question 6

What are the complications of SAH?

Answer 6

• Raised ICP due to blood spreading through the arachnoid space.
• Vasospasm in response to the bleeding causing secondary ischaemia.
• Rebleed risk.
• Permanent neurological defect due to infarction at the site of rupture.
• Death.

Question 7

What are the predisposing factors which make people vulnerable to suffering subdural haemorrhage?

Answer 7

Infants and the elderly.

Anything increasing bleeding risk:

• Anticoagulants
• Liver failure
• Alcoholism (poor clotting and brain atrophy)
• Inherited haemophilias

Question 8

What is the clinical presentation of an acute subdural haemorrhage?

Answer 8

Acute: Usually presents shortly after a moderate to severe head trauma.

There may be a loss of consciousness.

There may be a lucid period of a few hours where the patient seems relatively well before deteriorating and losing consciousness as a haematoma forms.

Question 9

What is the clinical presentation of a chronic subdural haemorrhage?

Answer 9

Chronic: Usually presents 2-3 weeks after the trauma, which may have been relatively uneventful (think of this in groups with a high bleeding risk)

Often a hx of progressive symptoms including: Anorexia, nausea and vomiting.

Focal neurology such as limb weakness, speech difficulties, confusion or personality change.

May be a progressively worsening headache (should really raise suspicion)

Question 10

Where exactly does a subdural haemorrhage occur?

Answer 10

It is a haemorrhage that occurs between dura and arachnoid mater.

Question 11

Describe the CT scan appearance of a subdural haemorrhage?

Answer 11

Subdural haemorrhages are typically unilateral (85%) and follow a crescent-like distribution around the periphery of the brain. They can cross suture lines.

In acute bleeds haemorrhage appears hyperdense (brighter)

Overtime (chronic subdurals) haemorrhage may dissapear leaving behind a hypodense (darker) area.

Question 12

Describe the following CT scan and the likely pathology?

Answer 12

Right sided acute SDH

Unilateral. Hyperdense (brighter) therefore acute. Cresenteric appearnce contiunous with outline of the brain.

Question 13

Describe the following CT scan and the likely pathology?

Answer 13

Chronic left sided SDH

Hypodense (darker) therefore chronic

Question 14

Describe the management of a patient with a subdural haemorrhage?

Answer 14

A-E assessment and stabilisation

Consider mannitol if intercranial pressure is raised

Referral to neurosurgery treatment is emergency craniotomy and clot evacuation.

Question 15

Which structural lesions which predispose to intracerebral haemorrhage?

Answer 15

Arteriovenous malformations. (abnormal anastomoses between arteries and veins)

Cerebral amyloid angiopathy: accumulation of amyloid in the tunica media and adventivia of vessels making them increasingly fragile. This is the major cause in lobar intrecerebral haemorrhage.

Tumours which are often highly vascular.

Question 16

Which other factors predispose to intracerebral haemorrhage?

Answer 16

Hypertension: is the major cause in deep intracerebral bleeds

Anticoagulant therapy

Ilicit drugs: sympathomimmetics aka cocaine, amphetamine and ecstasy

Question 17

Define intracerebral haemorrhage?

Answer 17

A bleed within to the brain itself it is classified as either:

Deep

or

Lobar (within the lobes)

Question 18

Describe the clinical presentation of a intracerebral haemorrhage?

Answer 18

The classic presentation of ICH is sudden onset of focal neurological deficit progressing over hours with accompanying headache, nausea, vomiting, altered consciousness, and elevated blood pressure.

Question 19

Describe the initial investigations and suspected immediate patient management in intracerebral haemorrhage?

Answer 19

CT angiography has the advantage over CT as it can be used to indicate still active bleeding.

Initial treatment: Resus, reduce ICP, prep for surgery.

Management is needed in an ITU setting.

A: Intubated

B: Hyperventialte to reduce ICP. CO2 causes vasodilation therefore low levels cause relative constriction therefore reduced cerebral blood flow and lower pressures.

C: Maintain euvolaemia.

Surgical management:

Insertion of a VP (ventricular peritoneal shunt) to reduce ICP and allow room for the haematoma to grow with out damaging brain tissue.

Main surgical aim is to remove the clot and stop further bleeding can be done by:

Stereotactic aspiration (preferred for large deep seated haematomas)

Or

Craniotomy (only when the bleed is more superficial)

Question 20

Describe how sterotactic aspiration is performed?

Answer 20

A metal stereotactic frame with for pins (screws) is attached to he patients head. A CT scan is taken with the frame on allowing the surgeon to pinpoint the exact coordinates of the haematoma.

The surgeon drills a small hole directly into the the haematoma and the clot is aspirated with a needle.

Question 21

Describe the clinical presentation of an extradural haemorrhage?

Answer 21

Typically there is a clear history of head trauma with a potential transient loss of conciousness.

Following this there is usually a lucid period in which they regain consciousness but usually have an ongoing severe headache.

Over the next few hours a haematoma forms and cause a mass effect herniation which presents clinically as gradual loss of consciousness.

Question 22

Which vessel is usually implicated in extradural haematoma’s?

Answer 22

Shearing of the middle meningeal aa just underlying the temporal bone. (inside the skull but outside the dura mater)

An associated skull fracture is present in 75% of cases.

Question 23

Describe the acute investigations and management of a suspected extradural haemorrhage?

Answer 23

Initial investigation should be a head CT which will demonstrate the haemorrhage.

Prognosis is usually good even in large haemorrhage as long as there is prompt evacuation of the clot by using burr holes.

In small haemorrhages they can be treated conservatively with monitoring. If there is worry about raised ICP mannitol can be given.