Intracranial haemorhage

Question 1

What are the different types of spontaneous intracranial haemorrhages?

Answer 1

SAH
Intracerebral
Intraventricular

Question 2

What is SAH?

Answer 2

Bleeding into the SAH
Usually underlying berry aneurysm
Sometimes AVM
Trauma

Question 3

What is the clinical presentation of SAH?

Answer 3

Sudden onset severe headache
Collapse
Vomiting
Neck pain
Photophobia

Question 4

DDx of sudden onset headache

Answer 4

SAH
Migraine
Benign coital cephalgia

Question 5

What are the signs of SAH?

Answer 5

Neck stiffness
Photophobia
Decreased conscious level
Focal neurological deficit (dysphagia, hemiparesis, 3rd nerve palsy)
Fundoscopy; retinal or vitreous haemorrhage

Question 6

What is the initial investigation in a suspected SAH?

Answer 6

CT scan

Question 7

What will an LP show in SAH?

Answer 7

Bloodstained or xanthochromic CSF (6-48 hrs)

Question 8

How is cerebral angiography performed?

Answer 8

Seldinger technique via femoral artery

Digital subtraction

Question 9

What is the gold standard in SAH?

Answer 9

Cerebral angiography/ CTA

Question 10

Why can cerebral angiography miss an angiography?

Answer 10

Vasospasm; all patients with SAH will be give nimodipine

Question 11

What are the complications post SAH?

Answer 11

Re-bleeding
Delayed ischaemic deficit
Hydrocephalus
Hyponatremia
Seizures

Question 12

What can be done to help prevent re-bleeding in SAH?

Answer 12

Endovascular techniques

Surgical clipping

Question 13

When does delayed ischaemic neurological deficit tend to occur?

Answer 13

Days 3-12

Question 14

What can be done to help prevent delayed ischaemia?

Answer 14

Prevent vasospasm; nimodipine

Triple H therapy; hypervolaemia, hypertensive, daemodilation

Question 15

What is the treatment for hydrocephalus?

Answer 15

CSF drainage via:
LP
EVD
Permanently; shunt

Question 16

What can cause hyponatremia?

Answer 16

SIADH

Cerebral salt wasting

Question 17

Do you fluid restrict for hyponatremia in SAH?

Answer 17

NO; supplement sodium intake or give fludrocortisone

Question 18

Is the seizure risk increased acutely and post SAH?

Answer 18

Yes; some will give anticonvulsant prophylaxis

Question 19

What should the initial treatment and investigations be in SAH?

Answer 19

Bedrest
Analgesia
Anti-emetic 
IV fluids
CT scan brain
LP
Refer to neurosurgeons

Question 20

What is the commonest cause of intracerebral haemorrhage?

Answer 20

Secondary hypertension

Question 21

What is the pathogenesis of hypertensive ICH?

Answer 21

Charcot-bouchard microaneurysms arising on small perforating areas

Question 22

Which area of the brain is most commonly affected by hypertensive ICH?

Answer 22

Basal ganglia and internal capusle

Question 23

What is the presentation of an ICH?

Answer 23

Headache; not as sudden onset or as severe as SAH
Focal neurological deficit
Decreased conscious level; increased ICP leads to reduced CCP

Question 24

What are the recommended investigations of an ICH?

Answer 24

CT scan; URGENT if decreased GCS

Angiography if suspicion of underlying vascular anomaly

Question 25

What is the treatment of an ICH?

Answer 25

Surgical evacuation of haematoma +/- treatment of underlying abnormality
Non-surgical management; if haemorrhagic stroke refer to stroke team

Question 26

What is the prognosis post ICH?

Answer 26

Good; if small superficial clot

Poor; if large basal ganglia or thalamic clot with major focal deficit or deep coma

Question 27

When do intraventricular haemorrhages occur?

Answer 27

Rupture of subarachnoid or intracerebral bleed into a ventricle

Question 28

Where will blood tend to pool in intraventricular haemorrhages on CT?

Answer 28

Occipital horns of lateral ventricles

Question 29

What can AVMs cause?

Answer 29

Seizures
Haemorrhage; ICH, SAH, subdural
Headache
Steal syndrome

Question 30

What is the treatment for AVMs?

Answer 30

Surgery
Endovascular embolisation
Stereotactic radiotherapy
Conservative