Intracranial Haemorrhage

Question 1

3 types of spontaneous intracranial haemorrhage?

Answer 1

subarachnoid
intracerebral
intraventricular

Question 2

what usually causes subarachnoid haemorrhage?

Answer 2

berry aneurysm (usually in the circle of willis at the base of the brain in the CSF)
sometimes AVM or no underlying cause

Question 3

how does subarachnoid haemorrhage present?

Answer 3

very sudden severe onset persistent explosive headache (thunderclap, like being hit with a bat)
collapse
vomiting
neck pain
photophobia
- meningitis symptoms

Question 4

benign coital cephalgia?

Answer 4

sudden onset severe headache during sex

Question 5

what are the signs of SAH?

Answer 5

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

Question 6

how is SAH diagnosed?

Answer 6

CT

• can be negative if >3 days since onset
• 15% false negative

Question 7

CSF vs blood on imaging?

Answer 7

CSF = low density = black
blood = high density = white

Question 8

what is seen on CT in SAH?

Answer 8

white areas around the base of the brain

often in shape of circle of willis in the middle

Question 9

what is done if CT is negative but SAH is suspected?

Answer 9

lumbar puncture

- shows bloodstained or xanthochromic (yellow) CSF from 6-48 hrs

Question 10

when is lumbar puncture done in suspected SAH?

Answer 10

after 12 hours to prevent traumatic tap
only done in alert patient with no focal neurological deficit or papilloedema
after normal CT scan

Question 11

after SAH is confirmed, how can the cause be diagnosed?

Answer 11

cerebral angiography

- seldinger technique injects contrast via femoral artery then CT or MRI imaging (usually CT)

Question 12

possible complications of SAH?

Answer 12

death
re-bleeding (often kills patients in later weeks-months)
delayed ischaemic deficit
hydrocephalus
hyponatraemia
seizures

Question 13

how are aneurysms managed to prevent rebleeding?

Answer 13

endovascular techniques

surgical clipping

Question 14

atheroma and aneurysm?

Answer 14

aneurysms often occur secondary to atheroma in vessels e.g from smoking

Question 15

what is DIND?

Answer 15

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

Question 16

how is DIND managed?

Answer 16

nimodipine (CCB)

high fluid intake (IV drip, triple H therapy)

Question 17

how does DIND appear on CT?

Answer 17

black area around where SAH occurred represents dead brain tissue from ischaemia

Question 18

how does hydrocephalus present?

Answer 18

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

Question 19

how is hydrocephalus managed?

Answer 19

CSF drainage (lumbar puncture, shunt, external ventricular drain)

Question 20

2 main reasons for hyponatraemia?

Answer 20

SIAHD
cerebral salt wasting (abnormal secretion of hormone causing sodium excretion)
both occur as a result of SAH

Question 21

how is hyponatraemia 2ndary to SAH managed?

Answer 21

do not fluid restrict (usually would but not if 2ndary to SAH as it would cause vasospasm)
supplement sodium intake
fludrocortisone

Question 22

how does SAH affect seizure risk?

Answer 22

increased risk

give anticonvulsant prophylaxis if seizures do occur

Question 23

what usually causes intracerebral haemorrhage?

Answer 23

most secondary to hypertension

2nd most common = aneurysm or AVM

Question 24

how does hypertension cause ICH?

Answer 24

charcot bouchard microaneurysms arise on small perforating arteries
basal ganglia haematoma

Question 25

how does ICH present?

Answer 25

headache
focal neurological deficit
decreased conscious level

Question 26

how is ICH investigated?

Answer 26

CT scan - urgent if decreased conscious level

angiography of suspicion of underlying vascular anomaly

Question 27

how is ICH managed?

Answer 27

surgical evacuation of haematoma +/- treat underlying abnormality (AVM etc)
non-surgical management

Question 28

describe the prognosis in ICH?

Answer 28

good if small superficial clot and good neurological status

poor if large basal ganglia or thalamic clot with major focal deficit or deep coma

Question 29

where is intraventricular blood most likely to be seen on CT?

Answer 29

occipital horns of ventricles (at the bottom due to gravity)

Question 30

what causes intraventricular haemorrhage?

Answer 30

rupture of subarachnoid or intracerebral bleed into a ventricle

Question 31

what is an AVM?

Answer 31

arterio-venous shunt
usually intraparenchymal (within brain tissue)
usually congenital

Question 32

what can an AVM cause?

Answer 32

seizures
haemorrhage (intracerebral, subarachnoid, subdural)
headache
steal syndrome

Question 33

how is an AVM managed?

Answer 33

can be surgically excised
endovascular embolization
stereotactic radiotherapy
conservative
weigh risks against benefits