Intracranial Haemorrhage

Question 1

What are the types of spontaneous intracranial haemorrhage?

Answer 1

Subarachnoid, intracerebral and intraventricular

Question 2

What is a subarachnoid haemorrhage?

Answer 2

Bleeding into the subarachnoid space = 46% mortality at 30 days even with treatment
Causes = AVM, berry aneurysm, spontaneous

Question 3

How do subarachnoid haemorrhages present?

Answer 3

Sudden onset severe headache, collapse, nausea/vomiting, neck pain and photophobia
Focal neurological deficit = dysphagia, hemiparesis, CN III palsy

Question 4

What are the differentials of a subarachnoid haemorrhage?

Answer 4

Migraine or benign coital cephalgia

Question 5

What may be seen on fundoscopy of a patient with a subarachnoid haemorrhage?

Answer 5

Retinal or vitreous haemorrhage

Question 6

What investigations are done for subarachnoid haemorrhages?

Answer 6

CT, lumbar puncture and cerebral angiography

Question 7

What are some features of a CT scan of a patient with a subarachnoid haemorrhage?

Answer 7

May be negative if >3 days post-ictus

Negative in 15% who have bled

Question 8

What are some features of a lumbar puncture of a patient with a subarachnoid haemorrhage?

Answer 8

Safe if normal CT or alert patient with no focal neurological deficit and no papilloedema
Bloodstained or xanthochromatic CSF (6-48hrs)

Question 9

What are the complications of a subarachnoid haemorrhage?

Answer 9

Rebleeding, delayed ischaemic deficit, hydrocephalus, hyponatraemia, seizures

Question 10

What are some features of a cerebral angiography in a patient with a subarachnoid haemorrhage?

Answer 10

Gold standard = Selder technique via femoral artery, 4 vessel angiography with multiple views
May miss aneurysm

Question 11

What are some features of rebleeding after a subarachnoid haemorrhage?

Answer 11

Often fatal = 20% risk in first 14 days, 50% risk in first 6 months

Question 12

What are some features of a delayed ischaemic deficit following a subarachnoid haemorrhage?

Answer 12

Days 3-12 usually
Altered conscious level or focal deficit
Treat with nimodipine and high fluid intake

Question 13

How is hyponatraemia caused by a subarachnoid haemorrhage treated?

Answer 13

Fludrocortisone

Question 14

What is the prognosis of a subarachnoid haemorrhage?

Answer 14

50% die in first month

50% of survivors have a major disability

Question 15

What is a intracerebral haemorrhage?

Answer 15

Bleeding into the brain parenchyma = 50% secondary to hypertension, 30% due to AVM or aneurysm

Question 16

What are some causes of a hypertensive intracerebral haemorrhage?

Answer 16

Charcot-Bouchard microaneurysms arising on small perforating arteries
Basal ganglia haematomas

Question 17

What is the presentation of an intracerebral haemorrhage?

Answer 17

Headache, focal neurological deficit, decreased conscious level

Question 18

What investigations are done for intracerebral haemorrhages?

Answer 18

CT = urgent if decreased conscious level

Angiography if suspicion of underlying vascular anomaly

Question 19

What is the treatment for intracerebral haemorrhages?

Answer 19

Surgical evaluation of haematoma +/- treatment of underlying abnormality

Question 20

What is the prognosis of an intracerebral haemorrhage?

Answer 20

Good prognosis of small superficial clot and good neurological status
Poor prognosis if large basal ganglia or thalamic clot with major focal deficit or deep coma

Question 21

What causes an intraventricular haemorrhage?

Answer 21

Rupture of a subarachnoid or intracerebral bleed into a ventricle

Question 22

What are arteriovenous malformations (AVMs)?

Answer 22

Arterio-venous shunts = usually intraparenchymal

Question 23

What are the symptoms of an AVM?

Answer 23

Seizures, haemorrhage, headache, steal syndrome

Question 24

What is the treatment of AVMs?

Answer 24

Surgery, endovascular embolisation, stereotactic radiotherapy, conservative

Question 25

What is first line for imaging aneurysms?

Answer 25

DSA = digital subjective angiography