Intracranial Haemorrhage Flashcards
3 types of spontaneous intracranial haemorrhage?
subarachnoid
intracerebral
intraventricular
what usually causes subarachnoid haemorrhage?
berry aneurysm (usually in the circle of willis at the base of the brain in the CSF) sometimes AVM or no underlying cause
how does subarachnoid haemorrhage present?
very sudden severe onset persistent explosive headache (thunderclap, like being hit with a bat) collapse vomiting neck pain photophobia - meningitis symptoms
benign coital cephalgia?
sudden onset severe headache during sex
what are the signs of SAH?
meningitic - neck stiffness, photophobia
can have decreased conscious level
can have focal neurological deficit (CN III palsy, dysphasia, hemiparesis etc)
retinal or vitreous haemorrhage on fundoscopy
how is SAH diagnosed?
CT
- can be negative if >3 days since onset
- 15% false negative
CSF vs blood on imaging?
CSF = low density = black blood = high density = white
what is seen on CT in SAH?
white areas around the base of the brain
often in shape of circle of willis in the middle
what is done if CT is negative but SAH is suspected?
lumbar puncture
- shows bloodstained or xanthochromic (yellow) CSF from 6-48 hrs
when is lumbar puncture done in suspected SAH?
after 12 hours to prevent traumatic tap
only done in alert patient with no focal neurological deficit or papilloedema
after normal CT scan
after SAH is confirmed, how can the cause be diagnosed?
cerebral angiography
- seldinger technique injects contrast via femoral artery then CT or MRI imaging (usually CT)
possible complications of SAH?
death re-bleeding (often kills patients in later weeks-months) delayed ischaemic deficit hydrocephalus hyponatraemia seizures
how are aneurysms managed to prevent rebleeding?
endovascular techniques
surgical clipping
atheroma and aneurysm?
aneurysms often occur secondary to atheroma in vessels e.g from smoking
what is DIND?
delayed ischaemic neurological deficit
tendency for patients to develop cerebral ischaemia 3-12 days after SAH
irritation after bleeding and blood breakdown products floating around brain causes vessels to spasm/occlude
causes altered conscious level or focal deficit
how is DIND managed?
nimodipine (CCB)
high fluid intake (IV drip, triple H therapy)
how does DIND appear on CT?
black area around where SAH occurred represents dead brain tissue from ischaemia
how does hydrocephalus present?
increasing headache over a week or so or altered conscious level if bad
often transient
present in most SAH cases but not always needed to treat
how is hydrocephalus managed?
CSF drainage (lumbar puncture, shunt, external ventricular drain)
2 main reasons for hyponatraemia?
SIAHD
cerebral salt wasting (abnormal secretion of hormone causing sodium excretion)
both occur as a result of SAH
how is hyponatraemia 2ndary to SAH managed?
do not fluid restrict (usually would but not if 2ndary to SAH as it would cause vasospasm)
supplement sodium intake
fludrocortisone
how does SAH affect seizure risk?
increased risk
give anticonvulsant prophylaxis if seizures do occur
what usually causes intracerebral haemorrhage?
most secondary to hypertension
2nd most common = aneurysm or AVM
how does hypertension cause ICH?
charcot bouchard microaneurysms arise on small perforating arteries
basal ganglia haematoma
how does ICH present?
headache
focal neurological deficit
decreased conscious level
how is ICH investigated?
CT scan - urgent if decreased conscious level
angiography of suspicion of underlying vascular anomaly
how is ICH managed?
surgical evacuation of haematoma +/- treat underlying abnormality (AVM etc)
non-surgical management
describe the prognosis in ICH?
good if small superficial clot and good neurological status
poor if large basal ganglia or thalamic clot with major focal deficit or deep coma
where is intraventricular blood most likely to be seen on CT?
occipital horns of ventricles (at the bottom due to gravity)
what causes intraventricular haemorrhage?
rupture of subarachnoid or intracerebral bleed into a ventricle
what is an AVM?
arterio-venous shunt
usually intraparenchymal (within brain tissue)
usually congenital
what can an AVM cause?
seizures
haemorrhage (intracerebral, subarachnoid, subdural)
headache
steal syndrome
how is an AVM managed?
can be surgically excised endovascular embolization stereotactic radiotherapy conservative weigh risks against benefits
