Intracranial haemorrhage Flashcards
Name the 3 types of spontaneous intracranial haemorrhage
- Subarachnoid haemorrhage
- Intracerebral haemorrhage
- Intraventricular haemorrhage
What is subarachnoid haemorrhage (SAH)?
- Bleeding into the subarachnoid space
- Potentially fatal if missed
- Even with treatment 46% 30 day mortality
- Usually underlying berry aneurysm
- Sometimes AVM or no underlying cause found
How does SAH present?
- Sudden onset severe headache
- Collapse
- Vomiting
- Neck pain
- Photophobia
What would be the differential diagnoses of sudden onset headache?
SAH, migraine, benign coital cephalgia
What are the clinical signs of SAH?
- Neck stiffness
- Photophobia
- Decreased conscious level
- Focal neurological deficit - dysphasia, hemiparesis, CN III palsy
- Fundoscopy - retinal or vitreous haemorrhage
What would a CT scan show in SAH?
- May be negative if >3 days post ictus
- Negative in 15% of patients who have bled
What would be present in the CSF if a lumbar puncture were performed for a patient with a SAH?
- Safe to perform in alert patient with no focal neurological deficit and no papilloedema or after normal CT scan
- Bloodstained or xanthochromic CSF (6-48 hour)
- Differentiate from traumatic tap
How is cerebral angiography performed in SAH?
- Seldinger technique via the femoral artery
- Digital subtraction 4 vessel angiography with multiple views
- Gold standard but occasionally may miss an aneurysm due to vasospasm
- MR and CT techniques increasingly used
What are some of the complications of SAH?
- Re-bleeding - 20% risk in first 14 days, 50% in first 6 months
- Delayed ischaemic deficit
- Hydrocephalus
- Hyponatraemia
- Seizures
What is delayed ischaemia and how is it treated?
- Delayed ischaemic neurlogical deficit occurs days 3-12 after SAH
- Altered conscious level or focal deficit
- Vasospasm
- Treatment:
- Nimodipine
- High fluid intake ‘Triple H therapy’ (hypertension, hypervolaemia, haemodilution)
What is hydrocephalus and how is it treated?
- Increased intracranial CSF pressure
- 6% symptomatic - increasing headache or altered conscious level
- Often transient
- Treatment - CSF drainage - LP, EVD, shunt
What is the cause of hyponatraemia in SAH and how is it treated?
- SIADH - syndrome of inappropriate anti-diuretic hormone release
- Often transient
- Do not fluid restrict
- Supplement sodium intake
- Fludrocortisone to treat
What is the risk of seizures associated with SAH?
3% acute risk, 10% 5-year risk
Anti-convulsant prophylaxis
What is the prognosis in patients with SAH?
- 10% die at scene
- 20% die in first week
- 50% die in first month
- 50% of survivors have major disability
- 66% of successful patients never return to their previous occupation
What is an intracerebral haemorrahge?
- Bleeding into the brain parencyhma
- 50% secondary to hypertension
- 30% due to aneurysm or AVM
What investigations are done in ICH?
- CT scan - urgent if decreased conscious level
- Angiography if suspicion of underlying vascular anomaly
What is an intraventricular haemorrhage?
- Occurs with rupture of a subarachnoid or intracerebral bleed into a ventricle
- Any combination of subarachnoid, intracerebral and interventricular haemorrhage can occur
