Intracranial bleeds

Question 1

RF?

Answer 1

Head injury
Hypertension
Aneurysms
Ischaemic stroke can progress to haemorrhage
Brain tumours
Anticoagulants such as warfarin

Question 2

Presentation

Answer 2

Sudden onset headache is a key feature. They can also present with:

Seizures
Weakness
Vomiting
Reduced consciousness
Other sudden onset neurological symptoms

Question 3

Glasgow coma scale

Answer 3

The Glasgow Coma Scale (GCS) is a universal assessment tool for assessing the level of consciousness. It is worth learning for your exams and every day practice as it frequently appears.

It is scored based on eyes, verbal response and motor response. The maximum score is 15/15, minimum is 3/15. When someone has a score of 8/15 or below then you need to consider securing their airway as there is a risk they are not able to maintaining it on their own.

Eyes

Spontaneous = 4
Speech = 3
Pain = 2
None = 1
Verbal response

Orientated = 5
Confused conversation = 4
Inappropriate words = 3
Incomprehensible sounds = 2
None = 1
Motor response

Obeys commands = 6
Localises pain = 5
Normal flexion = 4
Abnormal flexion = 3
Extends = 2
None = 1

Question 4

Subdural Haemorrhage

Answer 4

Subdural haemorrhage is caused by rupture of the bridging veins in the outermost meningeal layer. They occur between the dura mater and arachnoid mater. On a CT scan they have a crescent shape and are not limited by the cranial sutures (they can cross over the sutures).

Subdural haemorrhages occur more frequently in elderly or alcoholic patients. These patients have more atrophy in their brains making vessels more likely to rupture.

Question 5

Extradural Haemorrhage

Answer 5

Extradural haemorrhage is usually caused by rupture of the middle meningeal artery in the temporo-parietal region. It can be associated with a fracture of the temporal bone. It occurs between the skull and dura mater. On a CT scan they have a bi-convex shape and are limited by the cranial sutures (they can’t cross over the sutures).

The typical history is a young patient with a traumatic head injury that has an ongoing headache. They have a period of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.

Question 6

Intracerebral Haemorrhage

Answer 6

Intracerebral haemorrhage involves bleeding into the brain tissue. It presents similarly to an ischaemic stroke.

These can be anywhere in the brain tissue:

Lobar intracerebral haemorrhage
Deep intracerebral haemorrhage
Intraventricular haemorrhage
Basal ganglia haemorrhage
Cerebellar haemorrhage
They can occur spontaneously or as the result of bleeding into an ischaemic infarct or tumour or rupture of an aneurysm.

Question 7

Subarachnoid Haemorrhage

Answer 7

Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of a ruptured cerebral aneurysm.

The typical history is a sudden onset occipital headache that occurs during strenuous activity such as weight lifting or sex. This occurs so suddenly and severely that it is known as a “thunderclap headache”.

They are particularly associated with cocaine and sickle cell anaemia.

Question 8

Principles of Management

Answer 8

Immediate CT head to establish the diagnosis
Check FBC and clotting
Admit to a specialist stroke unit
Discuss with a specialist neurosurgical centre to consider surgical treatment
Consider intubation, ventilation and ICU care if they have reduced consciousness
Correct any clotting abnormality
Correct severe hypertension but avoid hypotension