Intracranial haemorhage Flashcards
What are the different types of spontaneous intracranial haemorrhages?
SAH
Intracerebral
Intraventricular
What is SAH?
Bleeding into the SAH
Usually underlying berry aneurysm
Sometimes AVM
Trauma
What is the clinical presentation of SAH?
Sudden onset severe headache Collapse Vomiting Neck pain Photophobia
DDx of sudden onset headache
SAH
Migraine
Benign coital cephalgia
What are the signs of SAH?
Neck stiffness
Photophobia
Decreased conscious level
Focal neurological deficit (dysphagia, hemiparesis, 3rd nerve palsy)
Fundoscopy; retinal or vitreous haemorrhage
What is the initial investigation in a suspected SAH?
CT scan
What will an LP show in SAH?
Bloodstained or xanthochromic CSF (6-48 hrs)
How is cerebral angiography performed?
Seldinger technique via femoral artery
Digital subtraction
What is the gold standard in SAH?
Cerebral angiography/ CTA
Why can cerebral angiography miss an angiography?
Vasospasm; all patients with SAH will be give nimodipine
What are the complications post SAH?
Re-bleeding Delayed ischaemic deficit Hydrocephalus Hyponatremia Seizures
What can be done to help prevent re-bleeding in SAH?
Endovascular techniques
Surgical clipping
When does delayed ischaemic neurological deficit tend to occur?
Days 3-12
What can be done to help prevent delayed ischaemia?
Prevent vasospasm; nimodipine
Triple H therapy; hypervolaemia, hypertensive, daemodilation
What is the treatment for hydrocephalus?
CSF drainage via:
LP
EVD
Permanently; shunt
What can cause hyponatremia?
SIADH
Cerebral salt wasting
Do you fluid restrict for hyponatremia in SAH?
NO; supplement sodium intake or give fludrocortisone
Is the seizure risk increased acutely and post SAH?
Yes; some will give anticonvulsant prophylaxis
What should the initial treatment and investigations be in SAH?
Bedrest Analgesia Anti-emetic IV fluids CT scan brain LP Refer to neurosurgeons
What is the commonest cause of intracerebral haemorrhage?
Secondary hypertension
What is the pathogenesis of hypertensive ICH?
Charcot-bouchard microaneurysms arising on small perforating areas
Which area of the brain is most commonly affected by hypertensive ICH?
Basal ganglia and internal capusle
What is the presentation of an ICH?
Headache; not as sudden onset or as severe as SAH
Focal neurological deficit
Decreased conscious level; increased ICP leads to reduced CCP
What are the recommended investigations of an ICH?
CT scan; URGENT if decreased GCS
Angiography if suspicion of underlying vascular anomaly
What is the treatment of an ICH?
Surgical evacuation of haematoma +/- treatment of underlying abnormality
Non-surgical management; if haemorrhagic stroke refer to stroke team
What is the prognosis post ICH?
Good; if small superficial clot
Poor; if large basal ganglia or thalamic clot with major focal deficit or deep coma
When do intraventricular haemorrhages occur?
Rupture of subarachnoid or intracerebral bleed into a ventricle
Where will blood tend to pool in intraventricular haemorrhages on CT?
Occipital horns of lateral ventricles
What can AVMs cause?
Seizures
Haemorrhage; ICH, SAH, subdural
Headache
Steal syndrome
What is the treatment for AVMs?
Surgery
Endovascular embolisation
Stereotactic radiotherapy
Conservative
