Intracranial Haemorrhage Flashcards
Name the 3 different types of spontaneous intracranial haemorrhage.
- Subarachnoid
- Intracerebral
- Intraventricular
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space
If a diagnosis of an SAH is missed, it can be fatal
TRUE
Even with treatment, what is the 30 day mortality of SAH?
46%
What is there usually underlying in an SAH?
Berry aneurysm
What else can an SAH be due to?
AVM
What symptoms does SAH usually present with?
- Sudden onset severe headache
- Collapse.
- Vomiting.
- Neck pain.
- Photophobia.
What may a patient describe the pain of an SAH as?
Like being hit on the back of the head with an axe
Name 3 differentials of a sudden onset severe headache.
- SAH
- Migraine
- Benign coital cephalgia
What signs are associated with SAH?
- Neck stiffness.
- Photophobia.
- Decreased conscious level.
- Focal neurological deficit (dysphasia, hemiparesis, IIIrd nerve palsy).
- Fundoscopy – retinal or vitreous haemorrhage.
Why will most patients with SAH not let you do fundoscopy?
They usually have very severe photophobia and thus do not want a light shone in their eye
What is the sign of a 3rd nerve palsy?
Dilated pupil, directed downwards and outwards
What is THE diagnostic test of SAH?
CT
If a CT is negative in SAH, what should be done?
Lumbar puncture
Why might a CT be negative in SAH?
> 3 days post -ictus
How does fresh blood appear on a CT?
Hyperdense - white
Who is an LP safe in?
- Alert pts with no focal neurological deficit, and no papilloedema
OR
- After normal CT scan
In the context of SAH, what results would you expect from a lumbar puncture? When?
Bloodstained or xanthochromic CSF (6-48hr) – yellow CSF due to breakdown of blood
What do you need to differentiate between in a lumbar puncture with blood?
Traumatic tap
How do you know if it is a traumatic tap and not SAH?
Take 3 samples - if the 1st one contains blood but the 3rd one is clear then it can be said to be a traumatic tap
Describe cerebral angiography.
- Seldinger technique via femoral artery
- Digital Subtraction
- 4 vessel angiography with multiple views
What test is GOLD standard but may miss an aneurysm due to vasospasm?
Cerebral angiography
Mushroom cloud
Aneurysm
What are the 5 main complications of an SAH that you must be aware of?
- Re-bleeding. (MAIN CONCERN)
- Delayed ischaemic deficit.
- Hydrocephalus.
- Hyponatraemia.
- Seizures.
Re-bleeds are _____
FATAL
What 2 techniques can be used to reduce the risk of a re-bleed?
- Endovascular techniques
* Surgical clipping
What may delayed ischaemia lead to?
Delayed Ischaemic Neurological Deficit (DIND).
In what days are most people most vulnerable to delayed ischaemia?
days 3-12
How does delayed ischaemic manifest itself?
With altered conscious level or focal deficit
Delayed ischaemia is due to what?
VASOSPASM
What drug is given to treat delayed ischaemia?
NIMODIPINE
What kind of drug is nimodipine?
Ca channel blocker
As well as Nimodipine, what else is used to treat delayed ischaemia?
High Fluid Intake ‘Triple H Therapy.’
- Hypervolaemia.
- Haemodilution.
- Hypertension.
What is hydrocephalus?
Increased intracranial CSF pressure
What is hydrocephalus known colloquially as?
‘water on the brain’
What are the main symptoms associated with hydrocephalus?
- Increasing headache.
* Altered conscious level.
Most people with ___ get hydrocephalus
SAH
What treatment options are available for hydrocephalus?
CSF drainage, either with:
- Lumbar puncture.
- External Ventricular Drain (EVD).
- Shunt (if something more permanent is needed).
Hydrocephalus is often ___________
TRANSIENT
What does hyponatraemia occur due to?
SIADH
or
‘Cerebral salt wasting.’
Hyponatraemia is often ____________
TRANSIENT
What should you not do in someone with hyponatraemia? Why?
Fluid restrict.
- blood will circulate less well, and will predispose pt to delayed ischaemia.
How should you manage a patient with hyponatraemia caused by SAH?
- Supplement sodium intake.
* Give fludrocortisone.
How is the risk of seizures managed in a patient with SAH?
Prophylactic anti-convulsants
What should you always think if a patient presents with a sudden onset severe headache for the first time?
‘Could this be SAH?’
What should you always do if a patient presents with SAH?
- Bedrest, analgesia, anti-emetic, IV fluids
- CT
- LP if CT negative
- Refer to neurosurgery
What is an intracerebral haemorrhage?
Bleed into brain parenchymal
What are 50% of ICH’s due to?
Hypertension
What are 30% of ICH’s due to?
Aneurysm, or arteriovenous malformation
Describe the headache in ICH.
These also cause a headache, but it is not as sudden and dramatic as that in SAH.
What is hypertensive ICH associated with?
- ‘Charcot-Bouchard’ microaneurysms, arising on small perforating arteries.
- Basal ganglia haematoma
Outline the presentation of ICH.
- Headache
- Focal neurological deficit. (hemiplegia or hemiparesis)
- Decreased conscious level
What is the GOLD standard investigation in ICH?
CT
When should a CT be done urgently in ICH?
If the patient has a decreased conscious level
When should angiography be done in someone with ICH?
If there is suspicion of underlying vascular anomaly.
note: most are due to hypertension, not a vascular abnormality
How is ICH managed?
With SURGICAL EVACUATION OF HAEMATOMA +/- treatment of underlying abnormality
OR
Non-surgical
When is the prognosis of ICH good?
If there is a small superficial clot, and good neurological status
When is the prognosis of ICH poor?
If there is a large basal ganglia or thalamic clot, with a major focal deficit or deep coma
What does an intraventricular haemorrhage occur due to?
Rupture of a subarachnoid or intracerebral bleed into a ventricle
Any combination of what can occur in an intraventricular haemorrhage?
Subarachnoid, intracerebral and intraventricular haemorrhage
What do AV malformations result in?
AV shunt
What – in terms of location – are AVM’s usually?
Intraparenchymal
AVM’s may be _________
CONGENTIAL
What are AVM’s associated with?
Seizures
Headache
What type of haemorrhage can AVM’s be associated with?
Intracerebral
Subarachnoid
Subdural
Steal syndrome seen in AVM’s can be described as……
Pull arterial blood from other arteries of the brain
What are the treatment options for AVM’s?
- Surgery
- Endovascular embolization
- Stereotactic radiotherapy
- Conservative
What must always be done when deciding on a treatment option for AVM’s?
Outweigh benefits and risks
Name some random causes of spontaneous intracranial haemorrhage.
Bleeding diatheses
Tumours
Drugs (warfarin, heparin)
