Intracranial Bleeds

Question 1

What requires an immediate CT head?

Answer 1

• 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

Question 2

What requires a CT head within 8 hours

Answer 2

For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
• 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

If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.

Question 3

What is an epi-dural haemorrhage

Answer 3

Collection of blood between the inner surface of skull and periosteal dura mater. Nearly always secondary to trauma and/or skull fracture typically in younger patients (50%).

Question 4

What causes epi-dural bleeds?

Answer 4

90% of cases involve a severed artery – most commonly middle meningeal artery.
Venous involvement rare but is usually the result of a torn venous sinus.
EDH is supratentorial in 95% of cases.

Question 5

How does an epi-dural bleed present?

Answer 5

Patient will present with loss of consciousness (LOC) due to impact of initial injury
This will be followed by transient recovery with ongoing headache known as a ‘lucid interval’ in 40% of patients.
As haematoma enlarges, ICP will increase causing compression of the cerebrum and herniation of the uncus of the temporal lobe around the tentorium cerebelli and the patient will develop a fixed and dilated pupil due to the compression of the parasympathetic fibres of the third cranial nerve.
Bradycardia and raised BP are late signs of raised ICP

Question 6

What is the investigation of choice for an epidural bleed?

Answer 6

CT/MRI

Skull X-ray

Question 7

How should an epi-dural bleed be managed?

Answer 7

Stabilise and transfer urgently for neurosurgery
Prognosis generally good with early intervention
Small EDH can be observed and managed conservatively with neurological follow up
Large EDH require referral to neurosurgery for craniotomy and clot evacuation.

Question 8

What complications can occur from an epidural bleed?

Answer 8

Death usually occurs due to respiratory arrest

Permanent brain damage, coma, seizures, weakness, pseudoaneurysm and Arteriovenous fistula.

Question 9

What is a subdural bleed?

Answer 9

Collection of blood between meningeal dura mater and arachnoid mater due to haemorrhage from bridging veins

Question 10

How are sub-dural bleeds classified?

Answer 10

Could be acute (<3 days), subacute (3-11 days) or chronic (3 weeks), where the time represents how long between the accident and presentation of neurological symptoms.

Question 11

What usually causes sub-dural bleeds?

Answer 11

Bleeding occurs due to shearing forces on cortical bridging veins. Most often associated with trauma but can be spontaneous. Cerebral atrophy increases the risk of rupture i.e. ageing and alcoholism.

Question 12

Describe the signs and symptoms of a sub-dural bleed

Answer 12

Usually history of head trauma
Neurological abnormalities are seen in up to 80%
Subacute/chronic SDH more common in the elderly
May present with insidious onset of confusion and general cognitive decline like dementia
Sleepiness, headache, personality change or unsteadiness
Raised ICP, seizures and localising neurological signs

Question 13

How should a suspected sub-dural bleed be investigated?

Answer 13

CT/MRI

Question 14

How are sub-dural bleeds managed?

Answer 14

ACUTE collections need immediate neurosurgical intervention to relieve raised ICP
Symptomatic SUBACUTE/CHRONIC SDH are often treated via one or more burr holes or craniotomy.
If found incidentally and small then manage conservatively

Question 15

What is the prognosis from subdural bleeds?

Answer 15

Prognosis is relatively poor compared to EDH.
Mortality in acute subdural haematomas requiring surgery intervention may exceed 50%. Worse outcomes in patients who are anticoagulated. Full recovery may only be achieved in 20% of patients.

Question 16

What is a sub-arachnoid haemorrhage?

Answer 16

Collection of blood between arachnoid mater and pia mater, very often this is catastrophic.

Question 17

What are the risk factors for sub-arachnoid bleeds?

Answer 17

Previous aneurysm rupture 
Smoking and alcohol 
Metabolic disease – BP, obesity, diabetes
Family history 
Polycystic kidney disease 
Ethlers Danlos 
Neurofibromatosis 
Aortic coarctation

Question 18

What commonly causes sub-arachnoid bleeds?

Answer 18

Traumatic this is most common
Secondary to ruptured berry aneurysm (85% of idiopathic causes) usually anterior or posterior communicating artery or bifurcation of the middle cerebral artery
Anterior venous malformation
Encephalitis, vasculitis, tumour or idiopathic

Question 19

What are the signs and symptoms of a sub-arachnoid bleed?

Answer 19

Occipital thunderclap headache
Collapse, seizures, coma, nausea and vomiting.
Meningism (photophobia, neck stiffness)
3rd and 6th Nerve palsy
Subhylaid haemorrhage – in the eye
Sentinel warning headache sometimes described – possibly warning leak from aneurysm

Question 20

How should sub-arachnoid haemorrhages be investigated?

Answer 20

CT scan will be positive in 90% of cases, most sensitive in first 12 hours

If CT negative, then do LP looking for oxyhaemoglobin or xanthochromia after 12 hours. Must be in a certain ratio to bilirubin to confirm it isn’t blood from the trauma of the LP and as such only the 3rd sample is sent for testing.

Cranial angiography to locate the artery

Question 21

How are sub-arachnoid haemorrahges managed?

Answer 21

Referral to neurosurgery as soon as SAH confirmed
Regular neuro obs, BP, pupils and GCS assessment, repeat CT if deteriorating
Maintain cerebral perfusion by keeping well hydrated but keep SBP < 160
Nimodipine to prevent vasospasm due to bleeding

Question 22

What complications from sub-arachnoid haemorrhages should you be aware of?

Answer 22

Rebleeding, cerebral ischaemia, hydrocephalus and hyponatraemia