Intracranial Bleeds- Epidural and Subdural bleeds Flashcards
Epidural Haematoma:
Caused by:
- Direct trauma to the area
- Specifically trauma to the temporal bone
- Causes disruption to the middle meningeal artery
- Blood rapidly accumulates
- Midline shift
Epidural Haematoma
Presentation
- Initial GCS falls
- Then GCS may rise briefly
- GCS then can fall to 3
- Rapid herniation can occur
Subdural Haematoma
- Bleeding from bridging veins
- Rapid accel/deceleration can sheer veins causing bleeding
- Caused by falls but can be without direct trauma
- As subdural bleeding is vsnous it is low pressure
- Can form slowly and if on anti-cogulation more susceptible
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Subdural Haematoma
Presentation:
Younger patients:
- Acute after trauma, since little brain atrophy
- Headaches. LOC and neurological deficits
Elderly patients:
- More atrophy, therefore more time for blood to accumulate
- Will get slow chronic personality changes
- Dependant on where bleed is, focal neurological deficits
- Increasing falls
- confusion
Presentation in elderly can be subtle
Paediatrics:
- A SDH could be the cause of abuse
- Headache, vomitting, LOC and focal neurological deficits
- Seizures
- On examination patient may have enlarged head diametre and bulging fontanelle
- failure to thrive
Subarachnoid haemorrhage
Separated into Traumatic and Non Traumatic causes:
Trauma: (with trauma)
- Happens in conjunction with other types of bleeds, SBH/EH, small volumes do not cause focal signs
- The ‘other bleeding causes focal neurological signs’,will also decrease LOC and reduce GCS
- Risk of bleeding enhanced by use of concurrent anticougulation
Non-trauma:
- Most due to rupture of an aneurysm (80%) and rest due to arteriovenous malformation (AVM) or neoplasm
Aneurysms
- Mostly found in the Circle of Willis, incidence increases with history of family aneurysms
- Diseases associated with inc aneurysms: polycystic kidney disease and connective tissue disease eg, marfans and erler danlos syndrome
- Greater the aneurysm, greater the risk of blood loss into the subarachnoid space, leading to herniation and death
- In some aneurysms there are small leaks prior to full rupture, called a sentinel bleed
Subarachnoid haemorrhage
Aneurysm presentation
Aneurysm presentation:
- Headaches, vomiting, seizures, LOC
- Sentinel bleeds do not cause mass changes in the patient, will present from the history with a svere headache, peaks at onset, known as a thunderclap headache
- Expanding aneurysm can cause symptoms before rupture, cranial nerve iii runs close to the posterior communicating artery, so expanding artery here leads to eye being down and out
- Also lack of pupil constriction, pupil therfore stays dilated
Intracerbral/parenchymal haemorrhage
Traumatic causes:
- Caused by direct head injury with associated bleeds from other areas SDH/EH
Non Traumatic causes:
- Main cause is HTN, common sites include basal ganglia and thalamus, pons and cerebellum
- Patient will present with sudden onset headache, vomiting, seizure, dec LOC, focal neurological deficits (corresponding to part of brain affected)
- Use of sympathomimetics (cocaine, amphetamines) inc incidence
Intracranial Bleed
History and Physical Exam (1)
There will be various presentations:
- Headaches
- Neck pain
- Seizures
- Focal neurological symptoms
- LOC
Need to get a timeline
Intracranial Bleed
History and Physical Exam (2)
Tranmatic Epidural, Subdural, SAH and Parenchymal
For the following:
- Epidural
- Subdural
- Traumatic SAH
- Traumatic parenchymal
Need to get a history, the mechanism, was it witnessed by family, nursing home etc
If it was a ‘remote’ ie in the past, traumatic subdural Haematoma is there a change in personality, ae they unsteady?
Intracranial Bleed
History and Physical Exam (3)
Non Traumatic SAH
If able to speak to patient, need to know about headache:
- onset
- what does it feel like
- when it peaked
- over hours or days
- did it peak instantly
Intracranial Bleed
History and Physical Exam (4)
Non Traumatic parenchymal
Need to know about the headaches:
- onset
- associated symptoms
- focal neurological deficits: vision, motor, sensory, balance
As these bleeds are due to HTN, need to know about this:
- any meds
- any meds that might inc BP
Document time of examination
Investigations (1)
Epidural Haematoma
- First investigation is a non cotrast CT head. Bleeding will be white
- Ventricle will disappear due to pushing effect of haematoma
Subdural haematoma
- Blood underneath dura, will be more of a crescent shape
- Also push fx to minimize ventricles
Investigations (2)
Traumatic SAH
Will be seen in the SA space
Aneurysmal SAH
Most aneurysms arise from the Circle of Willis, blood will be around that area
Investigations (3)
Traumatic parenchymal haematoma
- Will occur where the trauma is, there is also a small subdural haematoma in this slide
Non traumatic parenchymal haematoma
- Usually caused by HTN
- Bleeding concentrates in the thalamus, basal ganglia, pons and cerebellum
Investigations (4)
Age of bleeding
Fresh blood is white
After two weeks becomes isodense with CSF
Makes diagnosis more difficult
Subacute subdural haematoma (mainly veinous)
- Bleeding slow and gradual
- therefore patient may not be investigated immediately
When there is a small amount of blood, hard to see on CT
Investigations (5)
suspicion for a sentinel bleed
- If patients have an aneurysmal SAH, may have sentinel bleeding
- Not picked up on CT, so order a lumbar puncture
- CSF will have evidence of RBCs and xanthochromia
Lumbar puncture (when is this done?)
- onset
- how good the CT scanner is
- who is interpreting results
- In high risk patients LP is gold standard
Management (1)
Airway
LOC , Airway protection, GCS below 8 intubate
Breathing
Give oxygen
Circulation
HR monitor to measure HR, BP and SATS
Management (2)
Avoid hypotension
- Low BP can cause death
- Give fluids eg saline
- Vasopressors
If parenchymal bleed caused by HTN
Treat HTN
Look out for Cushings Triad
- Bradycardia
- Hypertension
- Apnoea
Means that there is a critical increase in ICP
If not fixed brain can herniate
Management (3)
Specific treatment
Surgery/non surgical
Surgery:
Epidural
subdural
Saub arachnoid
Parenchymal
Management (4)
Specific treatment
Supportive
Supportive treatment:
- seizure control
- anticoagulant reversal
- decrease ICP
Seizure control:
- Benzodiazepenes
- Analgesis and sedation
Anticoagulation reversal
- Vitamin K
- Fresh frozen plasma
Decrease ICP
- Elevate head of patient to 30 degrees
- give mannitol or 3% hypertonic saline
- Generally need surgery
