Intracranial Bleeds Flashcards
1
Q
What are risk factors to intra-cranial bleeds?
A
- Head injury
- Hypertension
- Aneurysms
- Ischaemic stroke → can progress to haemorrhage
- Brain tumours
- Anticoagulants i.e. warfarin, DOACs
2
Q
What are the four main types of Intracranial bleeds?
A
- Extradural haemorrhage
- Subdural haemorrhage
- Subarachnoid haemorrhage
- Intra-cerebral haemorrhage
3
Q
What symptoms would make you suspect a patient could be having an intracranial bleed?
A
- Sudden onset headache
- Weakness
- Vomiting
- Reduced / Loss of consciousness
- Sudden onset neurological signs
4
Q
GLASGOW COMA SCALE:
- What are the elements of the GCS score?
- How much does each element score maximally?
- What is the maximum and minimum GCS?
- At what score should you think about securing airway?
- Discuss each score for the Eye element
- Discuss each score for the Verbal element
- Discuss each score for the Motor element
A
- EVM = Eyes, Motor, Verbal
- Eyes = 4 maximum, Verbal = 5 maximum, Motor = 6 maximum
- Maximum = 15, Minimum, 3
- Secure airway when GCS = 8
- Spontaneous, To speech, To pain, No response
- Orientated in time place person, Confused, Inappropriate words, Incomprehensible sounds, No response
- Obeys to command, Moves to localised pain, Flexion withdrawal from pain, Abnormal flexion, Abnormal extension, No response
5
Q
What is Cushing’s triad?
A
- Physiological response to raised ICP, whereby there is:
1. Bradycardia
2. Hypertension
3. Deep, irregular breathing
6
Q
- What is a subdural haemorrhage? How can they be classified?
A
- A collection of blood beneath the dura mater, the outermost layer of the meninges
- Can be classified based on age; acute, subacute, chronic
7
Q
What is the presentation of a subdural haemorrhage?
A
- Fluctuating level of consciousness, insidious physical / intellectual slowing
- Sleepiness
- Headache
- Personality change
- Unsteadiness
8
Q
- What is the pathophysiology of an acute or chronic subdural haemorrhage?
A
- Due to rupture of small bridging veins BETWEEN CORTEX AND VENOUS SINUS within the subdural space, causing a slow bleed over weeks to months (if chronic subdural) or due to high impact trauma (if acute subdural)
9
Q
- What is the first-line investigation for a suspected Subdural Haemorrhage?
A
CT
10
Q
What does an Subdural hemorrhage appear like on CT? What about Acute SDH vs. a Chronic SDH?
A
- Appears crescentic in shape, not limited by the suture lines (can cross over it)
- Acute Subdural Haemorrhage (< 3 days): hyperdense, lighter relative to brain tissue
- Chronic Subdural Haemorrhage (>15 days): hypodense, darker relative to brain tissue
11
Q
What patients are at risk of Subdural haemorrhage and why?
A
- Alcoholics and elderly patients, due to brain atrophy and fragile bridging veins → more likely to fall
- Epileptics → more likely to fall
- Babies, due to fragile bridging veins (Shaken baby syndrome)
12
Q
How are acute subdural haemorrhages managed?
A
- Reverse clotting abnormalities if any
- Small / incidental ones → managed conservatively
- Larger ones → Monitor ICP, decompressive craniectomy
13
Q
How are chronic subdural haemorrhages managed?
A
- Reverse clotting abnormalities if any
- Small / incidental → managed conservatively
- Larger ones → Surgical decompression with burr holes
14
Q
What are some differentials to a subdural haemorrhage?
A
- Dementia, stroke, CNS mass
15
Q
What is an extradural haemorrhage? In what patients is it most commonly seen and why?
A
- An acute bleed between the dura mater and the inner surface of the skull
- Commonly seen in young adults aged 20-30, due to low impact trauma
16
Q
What is the presentation of an extradural haemorrhage?
A
- History of head trauma
- Patient initially loses consciousness, then briefly regains consciousness “lucid interval”, then loses it again
- Lucid interval usually lasts 6-8 hours, but can last a few days
- During this phase, may have an increasingly severe headache, vomiting, confusion, seizures, may have hemiparesis with brisk reflexes, Babinski+
- The final loss of consciousness is due to expanding haematoma and brain herniation
- If bleeding continues → ipsilateral pupil dilates (CN3 palsy, “blown pupil”, bilateral limb weakness, breathing becomes deep and irregular
17
Q
- What is the most common cause of an extra-dural haemorrhage?
- What may be other causes?
- What is a pterion?
A
- Most commonly caused by rupture of the middle meningeal artery, due to trauma at the temporoparietal region (pterion)
- Can also occur due to middle meningeal vein or dural sinuses
- An anatomical landmark and is where the parietal, frontal, sphenoid and temporal bones fuse
18
Q
- What is the first-line investigation for a suspected extradural haemorrhage? Other investigations?
- What investigation is contraindicated?
- What does an extradural haemorrhage appear like on CT?
A
- Non-contrast head CT → First line
- X-Ray → Not first line because CT is better
- Angiography → When assessing a non traumatic aetiology i.e. AVMs
- LP is contraindicated
- Appears as a biconvex, lentiform hyperdense (lighter) collection limited by the suture lines of the skull
19
Q
What is the management of an Extra-dural haemorrhage?
A
- ABCDE assessment
- If needed, high flow O2, C-spine protection, intubation / ventilation
- Referral to neurosurgical team
- Urgent decompression and evacuation to reduce ICP by burr hole to relieve pressure where thickest
- Craniectomy
- Medical management
- Diuretics i.e. Mannitol → reduce ICP
- Anti-convulsants → reduce post-trauma seizures
- Prophylactic ABX → reduce meningitis
- Barbiturates → reduce ICP, to protect brain from anoxia / ischaemia
20
Q
What are poor prognostic factors of an Extra-dural haemorrhage?
A
- Low Glasgow Coma Scale
- Lack of lucid interval
- Pupil abnormalities
- Decerebrate rigidity (extensor posture)
21
Q
What is a subarachnoid haemorrhage?
A
- An intracranial haemorrhage defined as bleeding within the subarachnoid space (between pia mater and arachnoid mater)
22
Q
What are the clinical features of a Subarachnoid Haemorrhage?
A
- Sudden onset, occipital, thunderclap headache “worse of my life”
- Nausea and vomiting
- Symptoms of meningism → photophobia, neck stiffness
- Seizures
- COMA, SUDDEN DEATH
23
Q
What is the most common cause of a Subarachnoid Haemorrhage? What conditions are associated with this?
What drugs are associated with Subarachnoid Haemorrhage?
A
85% of cases → commonly caused by saccular "berry" aneurysms - Acute polycystic kidney disease - Ehler-Danlos Syndrome - Coarctation of the Aorta - Sickle cell Anaemia Drugs associated are cocaine
24
Q
Aside from intracerebral aneurysms, what are less common causes of Subarachnoid haemorrhage?
A
- Arteriovenous malformation
- Pituitary apoplexy
- Arterial dissection
- Mycotic (infective) aneurysms
- Perimesencephalic (idiopathic venous bleed)
25
Q
What is the first-line investigation to diagnose a Subarachnoid Haemorrhage? What is seen?
A
- CT of the head → Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system
26
Q
If the primary investigation for a Subarachnoid Haemorrhage is negative, what can be ordered? When is it done and why? What is seen?
A
- Lumbar puncture, usually performed 12 hours following onset of symptoms for development of Xanthochromia
- On LP may see raised Xanthochromia (broken down RBC) and a normal / raised opening pressure
27
Q
Once a subarachnoid haemorrhage is confirmed by CT / LP, how is the underlying course identified?
A
- CT intracranial angiogram→ To identify a vascular lesion e.g. aneurysm or AVM
- +/- digital subtraction angiogram (catheter angiogram)
28
Q
What ECG changes are associated with Subarachnoid Haemorrhage?
A
ST elevation
29
Q
What is the management of a Subarachnoid Haemorrhage?
A
- Referral to neurosurgery
- IF DUE TO ANEURYSM → Coil, or craniotomy + clips, must also be under bed rest, well-controlled BP and no straining
- IF DUE TO VASOSPASM → 21 days of Nimodipine
30
Q
What are complications of a Aneurysmal Subarachnoid Haemorrhage?
A
- Re-bleeding (30%)
- Vasospasm → 1-2 weeks later
- Hyponatremia → due to SIADH
- Seizures
- Hydrocephalus
- Death
31
Q
What are the indications for a Head CT within 1 hour of A&E presentation?
A
- GCS < 13 on initial assessment
- GCS < 15 at 2 hours post-injury
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
- Post traumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
32
Q
What are the indications for a Head CT within 8 hours of A&E presentation?
A
- Patient with head injury + Warfarin
- Patient with head injury + LOC or amnesia + …
- Age 65 years or older
- Any history of bleeding or clotting disorders
- Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
- More than 30 minutes’ retrograde amnesia of events immediately before the head injury
33
Q
- What is an Intracerebral Haemorrhage?
- What is an Intracerebral Haemorrhage aka?
- What are the risk factors for developing an Intracerebral Haemorrhage?
- What are the different types of Intracerebral Haemorrhage?
- What is the main investigation, what would you see?
- What is the main treatment?
A
- An intracerebral haemorrhage is a collection bleeding within the brain tissue
- Also known as an Intraparenchymal haemorrhage
- Hypertension, Vascular lesions i.e. AVMs, aneurysms, Cerebral amyloid angiopathy, Brain tumours, Previous infarct
- Lobar, deep, intraventricular, basal ganglia, cerebellar
- CT head, you will see hyperdense (white areas) in brain
- Conversative care under stroke physicians, but if large clots then surgery
