Intracranial Haemorrhages Flashcards
How can Intracranial Haemorrhages be sub-catagorised?
Extra-axial and Intra-axial haemorrhage
What is an Extra-axial Haemorrhage? - Give examples
A haemorrhage that occurs within the skull but outside the Brain tissue
e.g.
- Epidural.
- Subdural.
- Subarachnoid.
What is an Intra-Axial Haemorrhage? - Give examples
A haemorrhage occurring within the Brain tissue itself.
e.g.
- Intracerebral.
- Intraventricular.
What layers are an Epidural haemorrhage between?
Dural membrane and bone.
How do Epidural Haemorrhages occur?
Often trauma related (70-95% present with skull fracture)
- RTA, Falls, Assault
What is the most common source of blood in Epidural Haemorrhages?
Blood is most often arterial (e.g. Middle Meningeal A.)
How would a Patient with an Epidural Haemorrhage present clinically?
- Altered consciousness
PERIODS OF LUCIDITY and UNCONSCIOUSNESS. - Headache
- Vomiting
- Confusion / Seizures
- Aphagia (Inability to swallow)
What would an Epidural Heamorrhage be described as on CT.
A biconcave Lens
(Limited to the skull sutures where the dura adheres to the skull)
What is the management of an Epidural Haemorrhage?
Depends on the severity.
Can vary from observations and monitoring to immediate surgical evacuation.
What layers do subdural Haemorrhages occupy?
Bleeding occurs between the Dura and Arachnoid membrane.
What is the likely cause of Subdural haemorrhages?
Head trauma related.
- RTA, Assault, Falls.
What is the source of the bleeding in Subdural Haemorrhages?
Bleeding occurs as a result of tearing of the Bridging veins.
What clinical manifestations would a patient presenting with Subdural Haemorrhage exhibit?
Similar to Epidural (confusion, nausea/vomiting)
However typically older patient >65.
50% present with coma.
coning may follow.
Epilepsy occasionally occurs.
Neurological decline common.
What would be seen on CT with a Subdural Haemorrhage?
A crescent of blood around the brain tissue, with midline shift.
- Follows the contour of the skull as it is not restricted by skull sutures.
If absent but still suspicious check CSF cause there will be blood in this.
What is the management of Subdural haemorrhages?
Close monitoring.
Even large collections can resolve spontaneously.
If draining required:
- Acute haemorrhage: Craniotomy.
- Chronic Haemorrhage: Burr holes.
What layers are subarachnoid Haemorrhages between?
In the subarachnoid space (between Arachnoid membrane and Pia matter)
What are the likely causes of SAH?
Spontaneous arterial bleeding into the Subarachnoid space. (Accounts for 5% of strokes)
Causes of bleeding:
- Saccular (berry) aneurysms most common. (Cerebral A.)
- Arteriovenous malformation.
- Rare associations with bleeding disorders, tumours, Marfans or Ehlers-Danlos.
What are the Clinical Features SAH?
Sudden very severe headache. “thunderclap headache”
- Loss of Consciousness / Seizure
- nausea / vomiting.
- Coma
Meningismus - Following severe SAH, Stiff neck and positive kernig’s sign (like Meningitis).
What are the Investigations for SAH?
CT.
Can Do LP if High clinical suspicion but negative CT - 12hrs post onset.
- Blood present (pink CSF)
- yellowing of CSF due to haemolysis in older bleeds (Xanthochromia)
- Increase in CSF bilirubin.
- If patient presents after 8 hours, a negative CT scan does not rule out a SAH.
What is seen on CT of SAH?
Irregular shaped bleed, hyperattenuation in the subarachnoid space that expands bilaterally.
What is the management for SAH.
- Control Hypertension.
- Bed rest and supportive measures.
- Nimodipine (a CCB) reduces mortality - prevents vasospasm, thus optimising cerebral perfusion.
What are the causes of Intracerebral haemorrhages?
- Hypertension.
- Embolism.
- Brain Tumour.
- Bleeding Disorder.
- Drugs. (Oral Anticoagulants require investigation in severe headache regardless)
How would Intracerebral haemorrhages present clinically?
The Neurological signs and Symptoms depend on the are affected.
- Headache.
- Nausea / Vomiting.
- Decreased consciousness level.
Associated with coma and severe headache.
What is the treatment of Intracerebral haemorrhages?
- Essentially supportive
- Surgical decompression probably most beneficial to patient with lobar haemorrhage
What are Intraventricular Haemorrhages?
Bleeding Confined to the ventricular system of the brain.
What is the Aetiology of Intraventricular Haemorrhages?
- Occurs as a secondary phenomenon when intracerebral haemorrhage ruptures.
Or When SAH extends to the ventricles.
