Intracranial Haemorrhage Flashcards
Give an example of spontaneous intracranial haemorrhage.
- Subarachnoid harmorrhage.
- Intracerebral haemorrhage.
- Intraventricular haemorrhage.
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space.
What is usually the underlying cause of spontaneous subarachnoid haemorrhage?
Underlying berry aneurysm.
How do subarachnoid haemorrhages present?
- Sudden onset severe headache.
- Collapse
- Vomiting.
- Neck pain.
- Photophobia.
- Reduced consicous level.
- Focal neurological deficit.
- Fundoscopy: retinal or vitreous haemorrhage.
What focal neurological deficits may suggest subarachnoid haemorrhage?
- Dysphasia.
- Hemiparesis.
- CN III palsy.
What signs on fundoscopy would suggest subarachnoid haemorrhage?
Retinal or vitreous haemorrhage.
Why is CT brain not always reliable in subarachnoid haemorrhage?
- May be negative if >3 days post ictus.
- Negative in 15% of patients who have bled.
When is lumbar puncture safe in those with subarachnoid haemorrhage?
- Alert patient.
- No focal neurological deficit.
- No papilloedema.
- CT scan normal.
What might lumbar puncture show 6-48 hours after subarachnoid haemorrhage?
Bloodstained or xanthochromic CSF.
Need to differentiate from traumatic tap.
How is cerebral angiography performed in investigating subarachnoid haemorrhage?
- Seldinger technique via femoral artery.
- Digital subtraction.
- 4 vessel angiography with multiple views.
What is gold standard investigation in subarachnoid haemorrhage?
Cerebral angiography - but can miss aneurysm due to vasospasm.
Complications of subarachnoid haemorrhage?
- Re-bleeding.
- Delayed ischaemic deficit.
- Hydrocephalus.
- Hyponatraemia.
- Seizures.
Describe the effect of re-bleeding in subarachnoid haemorrhage.
- Often fatal.
- 20% risk in first 14 days.
- 50% risk in first 6 months.
How is rebleeding in subarachnoid haemorrhage managed?
- Endovascular techniques.
- Surgical clipping.
Describe delayed ischaemic neurological deficit in subarachnoid haemorrhage.
- Occurs in days 3-12 after SAH.
- Patient displays altered conscious level or focal deficit.
- Due to vasospasm.
How is delayed ischaemic neurological deficit in subarachnoid haemorrhage managed?
- Nimodipine.
- High fluid intake “Triple H therapy”.
How does hydrocephalus present?
- Increasing headache or altered conscious level.
- Often transient.
How is hydrocephalus managed?
- CSF drainage by LP, EVD (external ventricular drain), shunt.
What is hyponatraemia and where is it seen?
- Seen in SIADH or “cerebral salt wasting”.
Low sodium levels within body.
Management of hyponatraemia in those with SAH?
- Do NOT fluid restrict.
- Supplement sodium intake.
- Fludrocortisone.
How does fludrocortisone help in the management of hyponatraemia in SAH?
A corticosteroid which decreases natriuretic diuresis and incidence of hypovolaemia.
Helping to maintain sodium and volume homeostasis in SAH patients.
What is the risk of seizures following SAH and how is this managed?
- 3% acute risk.
- 10% 5 year risk.
- Anticonvulsant prophylaxis.
General management of SAH?
- Bedrest.
- Analgesia.
- Anti-emetic.
- IV fluids.
General investigation and referral of SAH?
- CT brain.
- LP.
- Neurosurgery referral.
What percentage of SAH survivors are left with major disability?
50%.
What percentage of “successfully treated” SAH patients never return to their previous occupation?
66%.
What percentage of patients die within 1 month of SAH?
50%.
What percentage of patients die within 1 week of SAH?
20%.
What percentage of patients die at the scene in SAH?
10%.
What is intracerebral haemorrhage?
- Bleeding into brain parenchyma.
50% of intracerebral haemorrhages are secondary to?
Hypertension.
Other than hypertension, what are the main causes of intracerebral haemorrhage?
- Aneurysm.
- Arteriovenous malformation.
What causes hypertensive intracerebral haemorrhage?
- “Charcot-Bouchard” microaneurysms arising on small perforating arteries.
- Basal ganglia haematoma.
How does intracerebral haemorrhage present?
- Headache.
- Focal neurological deficit.
- Decreased conscious level.
How is intracerebral haemorrhage investigated?
- CT scan: urgent if decreased conscious level.
- Angiography if suspicious of underlying vascular anomaly.
How is intracerebral haemorrhage managed?
- Surgical evacuation of haematoma +/- treatment of underlying abnormality.
- Or non-surgical management.
When is prognosis good in intracerebral haemorrhage?
- If small superficial clot.
- Good neurological status.
When is prognosis poor in intracerebral haemorrhage?
- If large basal ganglia or thalamic clot.
- Major focal deficit or deep coma.
When does intraventricular haemorrhage occur?
- Rupture of a subarachnoid or intracerebral bleed into a ventricle.
- Any combination of subarachnoid, intracerebral and intraventricular haemorrhage can occur.
What is an arteriovenous malformation?
- Arteriovenous shunts that are usually intraparenchymal.
How do arteriovenous malformations present?
- Seizures.
- Haemorrhage: intracerebral, subarachnoid, subdural.
- Headache.
- Steal syndrome.
What is steal syndrome?
Ischaemia resulting from a vascular access device e.g. arteriovenous fistula.
How are arteriovenous malformations managed?
- Surgery.
- Endovascular embolisation.
- Stereotatic radiotherapy.
- Conservative management.
Regardless of treatment, risk must be weighed against benefit.
Where does blood accumulate if the bridging cerebral vein ruptures?
Between dura and arachnoid.
Where does blood accumulate if a posterior communicating artery aneurysm ruptures?
Between arachnoid and pia.
Where does blood accumulate if the middle meningeal artery ruptures?
Between bone and dura.
