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Neurosurgery > Intracranial bleeding > Flashcards

Intracranial bleeding Flashcards

1
Q

What is the pressure in the skull? What is considered pathological?

A
  • Normally ≤15 mmHg in adults
  • Pathologic intracranial hypertension (ICH) is present at pressures ≥20 mmHg
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2
Q

What are symptoms of increased intracranial pressure?

A
  • Headache, vomiting, pupillary changes, impaired eye movement, depressed global consciousness, decrease of sensory/motor function, changes in vital signs
  • Symptoms in children are different: We will find bulging fontanels, cranial suture separation, increase of head circumference, high pitched crying
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3
Q

What can the neurosurgeon can do in case of an increase of intracranial pressure due to trauma or hematoma?

A

We can measure the ICP and perform a ventriculostomy, to reach the ventricular system with a catheter with 2 aims: to subtract more CSF and decrease the ICP, and the 2nd is to measure the ICP directly from the skull.

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4
Q

Ventriculostomy

A

Artificially created opening between the cerebral ventricles and either a sterile extracranial space (drainage bag) or the intracranial subarachnoid space (ventriculocisternostomy)

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5
Q

When there is no more CSF to subtract, the swelling is out of control, what can the neurosurgeon do?

A

Decompressive craniotomy

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6
Q

What is a decompressive craniotomy

A

Neurosurgical procedure in which part of the skull is removed to allow a swelling or herniating brain room to expand without being squeezed

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7
Q

What can cause SAH?

A

Berry aneurysm (at bifurcation of vessels in circle of Willis)
Trauma (dissecting
aneurysm)
Atherosclerosis (fusiform
aneurysm)
Infection (mycotic
aneurysm)
Arteriovenous malformation
(AVM)

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8
Q

What differentiates a normal arterial wall from one that has developed an anurism?

A
  • The normal arterial wall is composed of endothelium, internal elastic membrane (part of tunica intima), a muscular tunica media and adventitia
  • In the wall of aneurysm there is disrupted anatomy (disrupted resistance of the wall) – we have endothelium, no internal elastic lamina and media muscularis layer, just a fibro-hyaline tissue followed by the adventitia
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9
Q

Where do aneurysms form within the brain?

A
  • Aneurysms grow in the middle of a bifurcation of intracranial vessels
  • Most intracranial aneurysms (approximately 85 percent) are located in the anterior circulation, predominantly on the circle of Willis
  • ACA (30%), Posterior communicating artery (25%), Middle cerebral artery (20%)
  • Common sites include the junction of the anterior communicating artery with the anterior cerebral artery, the junction of the posterior communicating artery with the internal carotid artery, and the bifurcation of the middle cerebral artery
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10
Q

What are the different types of aneurysms?

A

They include:
- Saccular aneurysms
- Fusiform aneurysm
- Giant aneurysm (the diameter is >2.5 cm, can involve more than one artery)
- Mycotic aneurysms usually result from infected emboli due to infective endocarditis (caused by infected artery wall, these are not located in Circle of Willis, but in the distal part of the cranial vessels)

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11
Q

What can an aneurysm be divided into morphologically?

A

Neck, sack, and dome in saccular aneurysm

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12
Q

What are risk factors for intracranial aneurysm formation?

A

Include:
1) Smoking – one of the main risk factors
2) High blood pressure/hypertension
3) Alcohol consumption
3) Congenital resulting from inborn abnormality in arterial wall
4) Family history of brain aneurysms – SAH history in the same family seems to increase the risk of new SAH in the same family. Subjects with “Familial Intracranial Aneurysms (FIA)” run a risk >4.2x higher compared to general population to have an unruptured intracranial aneurysm
5) Age > 40y/o
6) Gender – women have an increased incidence compared to men (ratio 3:2)
7) Other disorders (ex: Ehlers-Danlos Syndrome, Polycystic Kidney Disease, Marfan Syndrome, Fibromuscular Dysplasia (FMD))
8) Presence of Arteriovenous Malformations (AVM)
9) Drug use (particularly cocaine)
10) Infection

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13
Q

What are risk factors for intracranial aneurysm rupture?

A

1) Smoking
2) High blood pressure/hypertension
3) Physical exertion (due to increased blood pressure)

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14
Q

What can risk factors for intracranial aneurysm be divided into?

A

Modifiable and non modifiable

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15
Q

What are modifiable risk factors for intracranial aneurysms?

A

1) High cholesterol level
2) Alcohol abuse
3) Arterial hypertension
4) Atherosclerosis
5) Cigarette smoke
6) Oral contraceptive

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16
Q

What are non modifiable risk factors for intracranial aneurysms?

A

1) Female sex
2) Genetic link for subarachnoid hemorrhage (SAH)
a. Autosomal dominant polycystic kidney disease (ADPCKD)

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17
Q

What are causes of subarachnoid hemorrhage?

A
  • Most subarachnoid hemorrhages (SAHs) are caused by ruptured intracranial saccular (berry) aneurysms
  • Around 20 percent of SAH cases are nonaneurysmal
18
Q

What is the cause of hemorrhagic stroke?

A

50/50 split between intracerebral and subarachnoid hemorrhage

19
Q

What are saccular aneurysms?

A

Thin-walled protrusions from the intracranial arteries that are composed of a very thin or absent tunica media, and an absent or severely fragmented internal elastic lamina (typical aneurysm formed by neck + sac + dome)

20
Q

What are fusiform aneurysms?

A
  • Fusiform aneurysms consist of enlargement or dilatation of the entire circumference of the involved vessel that may in part be formed due to atherosclerosis
  • The entire vessel is altered, so there is no neck or dome, but just a dilation of the entire vessel with a fusiform shape
21
Q

How are intracranial aneurysms formed?

A
  • It is believed that most intracranial aneurysms develop over a short period of hours, days, or weeks, attaining a size allowed by the elasticity limits of the aneurysmal wall; at this point, the aneurysm either ruptures or undergoes stabilization and hardening
  • Those aneurysms that do not rupture gain significant tensile strength due to compensatory hardening with formation of excessive collagen. Therefore, the likelihood of rupture decreases unless the size of the aneurysm is fairly large at the time of initial stabilization
22
Q

Clinical manifestations of SAH

A
  • Sudden-onset, severe headache typically described as the “worst headache of my life” (thunderclap headache)
  • Decreased global consciousness
  • Vomiting
  • Neck pain or stiffness
23
Q

SAH diagnosis

A
  • First step in the diagnosis of SAH is noncontrast head CT
  • A lumbar puncture should be done if the head CT is negative (mandatory if there is a strong suspicion of SAH despite a normal head CT)
  • If both tests are negative, they effectively eliminate the diagnosis of SAH as long as both tests are performed within two weeks of the event
  • CTA (site, morphology, may allow planning of treatment without DSA)
  • Digital subtraction angiography (type of malformation, the location, morphology, and vasospasm)
24
Q

CSF findings in SAH

A

Elevated opening pressure, an elevated RBC count that does not diminish from CSF tube 1 to tube 4, and xanthochromia (presence of bilirubin in CSF)

25
Q

When should SAH be considered?

A

SAH should be considered in any patient complaining of a severe headache of sudden onset

26
Q

Imaging techniques for SAH diagnosis

A
  • Non contrast CT (firs test)
  • CTA
  • Digital subtraction angiography (DSA)
  • MRA (less commonly used)
27
Q

CTA vs DSA for SAH diagnosis

A
  • ## Major advantage of CTA over DSA is the speed and ease with which it can be obtained, often immediately after the diagnosis of SAH is made by head CT, when the patient is still in the scanner
28
Q

How often do aneurysms rupture?

A

Most aneurysms do not rupture

29
Q

Size of aneurysm classification and incidence

A

There is classification regarding size –
a) Small (78%) – less than 12 mm
b) Large (20%) – 12-24 mm
c) Giant (2%) – more than 24 mm

30
Q

Prevalence of unruptured aneurism in angiographic imaging? How many have multiple ones?

A
  • 1-5% in general population
  • Of patients with cerebral aneurysms, 20 to 30 percent have multiple aneurysms
31
Q

Size of aneurysm and risk of rupture

A

The rates of aneurysmal rupture were lower in smaller aneurysms
- The size cutpoint for defining low risk of rupture was 7 mm
- Majority of aneurysms that bleed are less than 1 cm in diameter (aka most of bleedings are from small ones)
- However, aneurysms that are less than 0.5 cm diameter have less risk of bleeding

32
Q

Prevalence of aneurysms in italy

A
  • Prevalence of aneurysm in general population: 2-5% (more in central and north italy than south, may be due to lifestyle and dietary habits)
  • SAH per year: 10/100.000 every inhabitants
33
Q

Risk of unruptured aneurysm to rupture?

A

Annual risk of rupture of 1-2%

34
Q

Mortality rate of SAH due to ruptured aneurysm

A
  • Most likely of all cerebrovascular disturbances to result in death
  • Mortality within the first 30 days after SAH approaches 30 percent and is attributed largely to the effects of initial and recurrent bleeding
35
Q

What can intracranial aneurysms be divided into clinically?

A
  • Unruptured asymptomatic aneurysm (most patients, incidentally found during imaging)
  • Unruptured symptomatic aneurysm
  • Ruptured aneurysm
36
Q

Symptoms of unruptured symptomatic aneurism?

A

Symptoms include headache (which may be severe and comparable to the headache of SAH , blurred vision, cranial neuropathies (particularly third nerve palsy), pyramidal tract dysfunction, and facial pain; they are felt to be due to the mass effect of the aneurysm

37
Q

What happens once an aneurysm ruptures?

A
  • Rupture of an aneurysm releases blood directly into the cerebrospinal fluid (CSF) under arterial pressure
  • The blood spreads quickly within the CSF, rapidly increasing intracranial pressure
  • The blood often spreads into the intraventricular space, but can also spread into the brain parenchyma or rarely, the subdural space, depending on the location of the aneurysm
38
Q

How long is the bleeding from a ruptured aneurysm?

A

The bleeding usually lasts only a few seconds, but rebleeding is common and occurs most often within the first day.

39
Q

Which scales can be used to grade severity of SAH

A
  • Hunt-Hess scale
  • WFNS (world federation of neurosurgeons) system
  • Ogilvy and Carter grading system
  • Fisher scale
40
Q

Non aneurysmal causes of SAH

A

Potentially diverse causes including:
- perimesencephalic hemorrhage (accounts up to 2/3 of cases in case series, may be caused by spontaneous rupture of a small perforating artery or vein at the surface of the brainstem but in most cases, diagnostic testing is unable to definitively identify the cause of bleeding in perimesencephalic NASAH)
- Vascular malformations
- Intracranial arterial dissection
- Reversible cerebral vasoconstriction syndrome
- Cerebral venous thrombosis
- Traumatic SAH, and a variety of other etiologies

Neurosurgery (5 decks)

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