INTRACRANIAL BLEEDS- extra/subdural haematoma + SAH Flashcards
Risk factors- intracranial bleeds?
Risk factors
-Head injury
-Hypertension
-Aneurysms
-Ischaemic stroke can progress to haemorrhage
-Brain tumours
-Anticoagulants e.g. warfarin
Presentation- intracranial bleeds?
-Sudden onset headache
-Seizures, weakness, vomiting, reduced consciousness, other sudden onset neurological symptoms
what is used to assess the level of consciousness and what is it marked out of?
Glasgow coma scale
3-15
Eye opening response- out of 4
Verbal response- out of 5
Motor response- out of 6
15= best response
8 or less= comatose
3= totally unresponsive
Name the criteria for the eye opening response- GCC
4- spontaneously
3- to speech
2- to pain
1- unresponsive
Name the criteria for the verbal response- GCC
5- can orientate time, place + person
4- confused
3- inappropriate words
2- incoherent sounds
1- unresponsive
Name the criteria for the motor response- GCC
6- can follow commands
5- moves to localised pain
4- flex to withdraw from pain
3- abnormal flexion
2- abnormal extension
1- unresponsive
what should be done if GCS is 8/15 or below?
airway should be secured
what type of intracranial bleeds are spontaneous?
-intracerebral
-SAH
-haemorrhagic infarct
what type of intracranial bleeds are traumatic?
-subdural
-extradural
-contusion (surface bruising)
-intracerebral
-SAH
what is an extradural haematoma?
collection of blood between the dura and the skull
where does bleeding occur in extradural haematoma?
between the dura mater and the skull
what artery is ruptures in extradural haematoma?
middle meningeal artery
what fracture is associated with extradural haematoma?
temporal bone fracture
- Middle meningeal artery is located in temporo parietal region
- Pterion is weakest part of skull (where all the parts of skull join)
typical patient presenting with extradural haeatoma?
young patient with head trauma
presentation- extradural haematoma?
-On going headache
-N+V
-Decreased consciousness
-Confusion
-Unilateral fixed pupils, RAPD
-Period of improved neurological symptoms and consciousness (lucid period) followed by a rapid decline over hours
-Rapid decline as the haematoma gets large enough to compress the intracranial contents
investigations- extra dural haematoma?
Urgent CT
what is seen on CT of extradural haematoma?
-lens shape/ bi convex/ lemon shaped mass
treatment extradural haematoma?
urgent decompression surgery
where is blood found in a subdural haematoma?
between the dura and arachnoid mater
what vessel ruptures in subdural haematoma?
bridging veins (between dura mater and arachnoid mater)
who is more likely to get a subdural haematoma?
People with brain atrophy
-older patients
-alcoholics
are subdural haematomas unilateral or bilateral?
can be both
-more likely to be bilateral in children
presentation- subdural haematoma?
Slower onset of symptoms than epidural haematoma
* Fluctuating confusion/ consciousness
* Headaches
* N+V
* Neuro deficits
* Personality changes
* Incontinence
* Confusion
* Gait changes/ Hemiparesis
what can mass effect of subdural haematoma cause?
herniations
how does subdural haematoma present macroscopically?
liquified blood/ yellow fluid
investigations- subdural haematoma?
1st line= URGENT CT
what is seen on CT- subdural haematoma?
Crescent/ Concave/ banana shape
-Not limited to coronal sutures
difference between chronic and acute subdural haematoma on CT?
chronic- blood is hypodense
acute- blood is hyperdense
Blood is thicker when acute and so appears hyperdense
treatment- subdural haematoma?
Conservative:
Watch and wait for 2 weeks (can clear spontaneously)
* Raised ICP= Mannitol
* Repeat CT in 6 months
Large + symptomatic= BURR HOLE/ CRANIOTOMY
-Repeat CT in 2-3 days
what medication can be given for raised ICP in subdural haematoma?
Mannitol
subarachnoid haemorrhage- what?
-arterial bleeding into the subarachnoid space
-can be either spontaneous or traumatic
-accounts for 5% of strokes
causes of SAH?
-spontaneous or traumatic
ruptured berry aneurysm (PKD)= most common
AVM
Idiopathic
SAH- presentation?
Buzz word= Sudden onset ‘Thunderclap’ headache
-10/10 severe, ‘Worst headache of life’, Occipital headache, ‘hit in back of the head’
-Neck stiffness
-N + V
loss of consciousness/ collapse/ confusion/ seizure
-Photophobia
SAH- signs?
focal neurological deficit= CNIII palsy + RAPD
May see retinal/ vitreous haemorrhage on fundoscopy
SAH- investigations?
acute= immediate CT (SAH until proven otherwise)
Gold standard= cerebral angiography
-once diagnosis confirmed cerebral angiography is used to locate the bleed
can do Lumbar puncture:
-blood in CSF
-from 6 to 48 hours Xanthochromia
maangement for SAH?
Urgent referral to neurosurgery
-bed rest, analgesia, anti- emetic, IV fluids
another name for intracerebral haemorrhage?
intraparanchymal haemorrhage
what diseases are associated with SAH?
Disease Associations:
-Sickle cell anaemia
-CTD (Marfans, Ehlers Danlos)
-Neurofibromatosis
-ADPKD
what is an intracerebral haemorrhage?
bleeding into parenchyma
what sign is seen on CT for SAH?
star shaped
most common place for intracerebral haemorrhage to occur?
basal ganglia
most common cause of intracerebral haemorrhage?
hypertension
how is intracerebral haemorrhage diagnoses?
CT
treatment- intracerebral haemorrhage?
supportive measures (same as haemorrhagic stroke)
croup and contra coup- what?
Coup
-truama causing brain to move and strikes part of the skull where trauma was
Contra-coup
-when brain hits off the other side of skull from where the trauma was
