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CNS CLERKSHIP > Intracranial Haemorrhage > Flashcards

Intracranial Haemorrhage Flashcards

1
Q

Give an example of spontaneous intracranial haemorrhage.

A
  • Subarachnoid harmorrhage.
  • Intracerebral haemorrhage.
  • Intraventricular haemorrhage.
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2
Q

What is a subarachnoid haemorrhage?

A

Bleeding into the subarachnoid space.

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3
Q

What is usually the underlying cause of spontaneous subarachnoid haemorrhage?

A

Underlying berry aneurysm.

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4
Q

How do subarachnoid haemorrhages present?

A
  • Sudden onset severe headache.
  • Collapse
  • Vomiting.
  • Neck pain.
  • Photophobia.
  • Reduced consicous level.
  • Focal neurological deficit.
  • Fundoscopy: retinal or vitreous haemorrhage.
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5
Q

What focal neurological deficits may suggest subarachnoid haemorrhage?

A
  • Dysphasia.
  • Hemiparesis.
  • CN III palsy.
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6
Q

What signs on fundoscopy would suggest subarachnoid haemorrhage?

A

Retinal or vitreous haemorrhage.

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7
Q

Why is CT brain not always reliable in subarachnoid haemorrhage?

A
  • May be negative if >3 days post ictus.

- Negative in 15% of patients who have bled.

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8
Q

When is lumbar puncture safe in those with subarachnoid haemorrhage?

A
  • Alert patient.
  • No focal neurological deficit.
  • No papilloedema.
  • CT scan normal.
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9
Q

What might lumbar puncture show 6-48 hours after subarachnoid haemorrhage?

A

Bloodstained or xanthochromic CSF.

Need to differentiate from traumatic tap.

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10
Q

How is cerebral angiography performed in investigating subarachnoid haemorrhage?

A
  • Seldinger technique via femoral artery.
  • Digital subtraction.
  • 4 vessel angiography with multiple views.
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11
Q

What is gold standard investigation in subarachnoid haemorrhage?

A

Cerebral angiography - but can miss aneurysm due to vasospasm.

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12
Q

Complications of subarachnoid haemorrhage?

A
  • Re-bleeding.
  • Delayed ischaemic deficit.
  • Hydrocephalus.
  • Hyponatraemia.
  • Seizures.
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13
Q

Describe the effect of re-bleeding in subarachnoid haemorrhage.

A
  • Often fatal.
  • 20% risk in first 14 days.
  • 50% risk in first 6 months.
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14
Q

How is rebleeding in subarachnoid haemorrhage managed?

A
  • Endovascular techniques.

- Surgical clipping.

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15
Q

Describe delayed ischaemic neurological deficit in subarachnoid haemorrhage.

A
  • Occurs in days 3-12 after SAH.
  • Patient displays altered conscious level or focal deficit.
  • Due to vasospasm.
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16
Q

How is delayed ischaemic neurological deficit in subarachnoid haemorrhage managed?

A
  • Nimodipine.

- High fluid intake “Triple H therapy”.

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17
Q

How does hydrocephalus present?

A
  • Increasing headache or altered conscious level.

- Often transient.

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18
Q

How is hydrocephalus managed?

A
  • CSF drainage by LP, EVD (external ventricular drain), shunt.
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19
Q

What is hyponatraemia and where is it seen?

A
  • Seen in SIADH or “cerebral salt wasting”.

Low sodium levels within body.

20
Q

Management of hyponatraemia in those with SAH?

A
  • Do NOT fluid restrict.
  • Supplement sodium intake.
  • Fludrocortisone.
21
Q

How does fludrocortisone help in the management of hyponatraemia in SAH?

A

A corticosteroid which decreases natriuretic diuresis and incidence of hypovolaemia.

Helping to maintain sodium and volume homeostasis in SAH patients.

22
Q

What is the risk of seizures following SAH and how is this managed?

A
  • 3% acute risk.
  • 10% 5 year risk.
  • Anticonvulsant prophylaxis.
23
Q

General management of SAH?

A
  • Bedrest.
  • Analgesia.
  • Anti-emetic.
  • IV fluids.
24
Q

General investigation and referral of SAH?

A
  • CT brain.
  • LP.
  • Neurosurgery referral.
25
Q

What percentage of SAH survivors are left with major disability?

A

50%.

26
Q

What percentage of “successfully treated” SAH patients never return to their previous occupation?

A

66%.

27
Q

What percentage of patients die within 1 month of SAH?

A

50%.

28
Q

What percentage of patients die within 1 week of SAH?

A

20%.

29
Q

What percentage of patients die at the scene in SAH?

A

10%.

30
Q

What is intracerebral haemorrhage?

A
  • Bleeding into brain parenchyma.
31
Q

50% of intracerebral haemorrhages are secondary to?

A

Hypertension.

32
Q

Other than hypertension, what are the main causes of intracerebral haemorrhage?

A
  • Aneurysm.

- Arteriovenous malformation.

33
Q

What causes hypertensive intracerebral haemorrhage?

A
  • “Charcot-Bouchard” microaneurysms arising on small perforating arteries.
  • Basal ganglia haematoma.
34
Q

How does intracerebral haemorrhage present?

A
  • Headache.
  • Focal neurological deficit.
  • Decreased conscious level.
35
Q

How is intracerebral haemorrhage investigated?

A
  • CT scan: urgent if decreased conscious level.

- Angiography if suspicious of underlying vascular anomaly.

36
Q

How is intracerebral haemorrhage managed?

A
  • Surgical evacuation of haematoma +/- treatment of underlying abnormality.
  • Or non-surgical management.
37
Q

When is prognosis good in intracerebral haemorrhage?

A
  • If small superficial clot.

- Good neurological status.

38
Q

When is prognosis poor in intracerebral haemorrhage?

A
  • If large basal ganglia or thalamic clot.

- Major focal deficit or deep coma.

39
Q

When does intraventricular haemorrhage occur?

A
  • Rupture of a subarachnoid or intracerebral bleed into a ventricle.
  • Any combination of subarachnoid, intracerebral and intraventricular haemorrhage can occur.
40
Q

What is an arteriovenous malformation?

A
  • Arteriovenous shunts that are usually intraparenchymal.
41
Q

How do arteriovenous malformations present?

A
  • Seizures.
  • Haemorrhage: intracerebral, subarachnoid, subdural.
  • Headache.
  • Steal syndrome.
42
Q

What is steal syndrome?

A

Ischaemia resulting from a vascular access device e.g. arteriovenous fistula.

43
Q

How are arteriovenous malformations managed?

A
  • Surgery.
  • Endovascular embolisation.
  • Stereotatic radiotherapy.
  • Conservative management.

Regardless of treatment, risk must be weighed against benefit.

44
Q

Where does blood accumulate if the bridging cerebral vein ruptures?

A

Between dura and arachnoid.

45
Q

Where does blood accumulate if a posterior communicating artery aneurysm ruptures?

A

Between arachnoid and pia.

46
Q

Where does blood accumulate if the middle meningeal artery ruptures?

A

Between bone and dura.

CNS CLERKSHIP (43 decks)

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