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INTRACRANIAL BLEEDS Flashcards

1
Q

Layers of the meninges?

A

Dura mater - directly under the bones of the skull
Arachnoid mater - directly under dura mater
Pia mater - under the subarachnoid space and tightly adhered to the surface of the brain

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2
Q

What are the 2 layers of the dura mater and what lies between them?

A

Periosteal layer and meningeal layer
Dural venous sinuses are located in between

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3
Q

Function of the dural venous sinuses?

A

Venous drainage of the cranium and empty into the internal jugular veins

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4
Q

What are dural reflections and what are the 4 types?

A

These are where the meningeal layer of the dura mater fold inwards upon itself to divide the cranial cavity into several compartments
Falx cerebri, tentorium cerebelli, falx cerebelli, diaphagma sellae

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5
Q

What is contained within the subarachnoid space?

A

CSF

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6
Q

What are arachnoid granulations?

A

Small projections of arachnoid mater into the dura which allow for CSF to re-enter the circulation via the dural venous sinuses

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7
Q

What is a subarachnoid haemorrhage?

A

An intracranial haemorrhage where there is bleeding in the subarachnoid space (where CSF is located) - this is between arachnoid membrane and pia mater

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8
Q

Causes of subarachnoid haemorrhage?

A

Traumatic - head injury is the most common cause of SAH overall

Non-traumatic (spontaneous):
- rupture of intracranial saccular aneurysm - 85%
- AVMs
- pituitary apoplexy
- arterial dissections
- use of anticoagulants

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9
Q

Conditions associated with berry aneurysms?

A

Hypertension
Adult PCKD
Ehlers-danlos
Coarctation of the aorta

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10
Q

Presentation of subarachnoid haemorrhage?

A

Sudden-onset maximum severity occipital headache that peaks in intensity within 5 minutes
N&V
Meningism
Coma
Seizures

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11
Q

Risk factors for subarachnoid haemorrhages?

A

Age 45-70
Women
Black ethnic origin
Severe head injury
Hypertension
Smoking
Excessive alcohol
FHx
Cocaine use
SC anaemia
CTD
Neurofibromatoiss
ADPKD

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12
Q

Investigtaions for subarachnoid haemorrhage?

A

Non-contrast CT head - if this is done >6 hours after Sx onset and is normal then do an LP 12 hours following Sx

After SAH is confirmed CT intracranial angiogram +/- digital subtraction angiogram is done to find the causative

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13
Q

What will subarachnoid haemorrhage look like on a non-contrast CT?

A

Hyper dense (bright) blood distributed in basal cisterns, sulci and sometimes in severe cases the ventricular system

(Note: a negative CT head does not exclude a subarachnoid haemorrhage especially if after 6 hours!!)

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14
Q

Why must an LP be performed at least 12 hours after the onset of symptoms of ?subarachnoid haemorrhage?

A

To allow the development of xanthochromia which is a RBC breakdown product - this helps to distinguish SAH from a traumatic tap

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15
Q

Findings of CSF from an LP in a pt with ?subarachnoid haemorrhage?

A

Raised xanthochromia
May be a normal or raised opening pressure

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16
Q

Management of a confirmed aneurysmal subarachnoid haemorrhage?

A

Bed rest, analgesia, VTE prophylaxis, discontinue and reverse antithrombotics
Oral nimodipine
Interventional neuroradiology e.g. coil or clipping

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17
Q

What is endovascular coiling?

A

When you insert a catheter into the arterial system and place platinum coils in the aneurysm, sealing it off from the artery

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18
Q

Why do we give nimodipine following a confirmed subarachnoid haemorrhage?

A

To prevent vasospasm which is a common complication which can result in brain ischaemia

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19
Q

Complications of aneurysmal subarachnoid haemorrhage?

A

Re-bleeding - most common in first 12 hours - occurs in 10% and has a very high mortality
Hydrocephalus
Vasospasm (aka delayed cerebral ischaemia)
Hyponatraemia - usually due to SIADH
Seizures

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20
Q

poor prognostic factors for subarachnoid haemorrhage

A

Increased age
Low conscious level on admission
Large amount of blood visible on CT head

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21
Q

mortality rate of subarachnoid haemorrhage?

A

5% of people die before reaching hopsital or having brain imaging
25% dont survive to hospital discharge

22
Q

What is a subdural haemorrhage?

A

A collection of blood deep to the dural layer of the meninges and above the arachnoid layer

23
Q

What are the 3 types of subdural Haematoma?

A

Acute: symptoms develop within 48 hours of injury with rapid neurological deterioration
Subacute: symptoms manifest days-weeks post-injury with a gradual progression
Chronic: develop over weeks-months and pts may not recall a specific head injury - common in elderly

24
Q

Cause of a subdural haematoma?

A

Trauma - blow to the temporal side of the head, rupturing the bridging cranial veins bridging the dura and the brain

25
Who are subdural haematomas most common in?
Elderly Alcoholics (Both have brain atrophy making the vessels more prone to rupture)
26
Presentation of a chronic subdural haematoma?
History of head trauma with a lucid interval followed by a gradual decline in consciousness May also be headache, confusion and lethargy
27
Presentation of a subdural haematoma?
Altered mental status - mild confusion -> deep coma (fluctuations are common) Focal neurological deficits dependant on location Headache - often localised to 1 side and worsening over time Seizures Memory loss, personality changes or cognitive impairment N&V - secondary to raised ICP
28
Physical examination findings for subdural haematoma?
Papilloedema due to raised ICP Unilateral dilated pupil on side of haematoma due to compression of CN3 Gait ataxia or weakness in 1 leg Hemiaparesis or hemiplegia - reflecting mass effect and midline shift Bradycardia, hypertension and respiratory irregularities (Cushing’s triad)
29
Investigations for ?subdural haematoma?
FBC, U&Es, LFTs, coagulation studies and group & save Non-contrast CT head
30
How will CT head appearance vary dependaning on an acute or chronic subdural bleed?
Acute SDH typically has a hyperdense appearance (bright white). Chronic SDH typically has a hypodense appearance (black/dark grey).
31
Non-contrast CT head appearance of a subdural haematoma?
Crescent-shaped collection of blood overlying 1 of the cerebral hemispheres and not limited by suture lines May cause a midline shift or herniation if large enough to cause a mass effect
32
Management of a subdural haematoma?
Reversal of anticoagulation AEDs for 1 week to prevent seizures Conservative - if small with minimal mass effect and no neurological impairment Surgical options - trauma craniotomy or if large then a decompressive craniectomy If chronic then surgical decompression with burr hole craniotomy is done
33
Complications of subdural haematomas?
Transtentorial herniation Permanent neurological deficits Coma Cerebral oedema and raised ICP Seizures Intracranial infection Recurrent subdural haematoma Death
34
What is an extradural haematoma aka?
Epidural Haematoma
35
What is an extradural Haematoma?
An acute haemorrhage between the dura mater and the inner surface of the skull
36
What is the Pterion?
The anataomical landmark where the parietal, frontal, sphenoid and temporal bones fuse - particularly vulnerable to fracture as the bone is relatively thin
37
What lies underneath the pterion?
The middle meningeal artery - making it likely to rupture
38
Cause of extradural haematomas?
Usually a low impact trauma e.g. blow to the head or a fall Usually in the temporal region where the pterion is and this causes a rupture of the middle meningeal artery
39
Pathophysiology of an extradural haematoma?
Blood leaks from the middle meningeal artery into the extradural space which strings the dura mater away from the skull If it continues to increase in size, the ICP increases and this can cause midline short and tantentorial herniation
40
Presentation of an extradural haematoma?
History of trauma/fall Initially loses, briefly regains and then loses consciousness again and further deterioriation - termed “lucid intervals” N&V Headache
41
Examination findings in an extradural Haematoma?
Tenderness of skull Reduced GCS Cranial nerve deficits e.g. fixed dilation of ipsilateral pupil Motor or sensory deficits Hypereflexia and spasticity Babinskis sign Cushings triad - bradycardia, hypertension, irregular breathing
42
Investigtaions for ?extradural haematoma?
FBC, U&Es, CRP, coagulation and group & save Non-contrast CT head
43
CT findings in extradural haematoma?
Biconvex/lentiform hyperdense collection around the surface of the brain that is limited but the suture lines of the skull
44
Management of extradural haematoma?
Correct anticoagulation Prophylactic antibiotics may be given especially if open skull fracture AEDs Agents to reduce ICP may be given e.g. IV mannitol If it’s >30cm - manage surgically e.g. burr hole craniotomy or trauma craniotomy or hemicraniotomy Is <30cm with.. low thickness, minimal midline shift and GCS >8 and no focal neurological deficits = conservative management
45
Complications of extradural Haematoma?
Transtentorial coning -> coma and death Infection Cerebral ischaemia Seizures Cognitive impairment Hemiparesis Hydrocephalus Brainstem injury due to raised ICP
46
Overall mortality rate of extradural haematomas?
30%
47
Poor prognostic factors for extradural haematomas?
Older age Temporal location Low GCS at presentation Evidence of herniation or raised ICP
48
What is an intracerebral haemorrhage?
Aka a haemorrhagic stroke A collection of blood within the substance of the brain e.g. caused by hypertension, brain tumour, aneurysm, infarct Present similarity to an ischaemic stroke CT imaging shows a hyperdensity within the substance of the brain
49
What is terson syndrome?
Intraocular haemorrhage associated with SUH, intracerebral haemorrhage or TBI
50
Why can an oculomotor nerve palsy occur with a SAH?
Aneurysm of the posterior communicating artery can case it Increased ICP, midbrain injury or uncal herniation can also cause it

NEUROLOGY (16 decks)

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