Intracranial Haemorrhages Lecture

Question 1

Types of Spontaneous Intracranial Haemorrhage (3)

Answer 1

Subarachnoid
Intracerebral
Intraventricular

Question 2

Subarachnoid Haemorrage Presentation

Answer 2

Sudden onset severe headache
Collapse 
Vomiting
Neck Pain
Photophobia

spike in icp - headache
blood in csf space irritates meninges and lining - symptoms of meningitis - vomiting, neck pain, photophobia - difference between meningitis is onset
sentinel headache - a few patients complain of mild headache before big explosion

Question 3

Why could a CT brain be negative in a patient with SAH

Answer 3

May be negative if >3days post ictus

Negative in 15% of patients who have bled

Question 4

How do you differentiate a traumatic tap from blood in the CSF?

Answer 4

by collecting 3 samples - if traumatic tap blood amount decreases with each sample

Question 5

Cerebral angiography in SAH

Answer 5

Gold standard

May miss anuerysm occasionally due to vasospasm

Question 6

Complications of SAH (5)

Answer 6

Re-bleeding
Delayed ischaemic deficit
Hydrocephalus
Hyponatraemia
Seizures

Question 7

Delayed ischaemic neurological deficit
when does it occur?
what do we give?

Answer 7

day 3-12
Nimodipine - reduces size of neurological deficit
High fluid intake - triple h therapy

Question 8

What is an intracerebral haemorrhage?

Answer 8

Bleeding into brain parenchyma

Question 9

Causes of intracerebral haemorrhage (2)

Answer 9

50% secondary to hypertension

30% due to anuerysm or arteriovenous malformation

Question 10

Hypertensive ICH - pathology

Answer 10

Charcot bouchard microaneurysms arising on small perforating arteries
Basal ganglia haematoma

Question 11

Presentation of ICH

Answer 11

Headache
Focal neurological deficit
Decreased conscious level

not as sudden as sah as haemorrhage contained within brain
big bleed = raised icp = decreased conscious

Question 12

Investigations of ICH

Answer 12

CT scan - urgent if decreased conscious level

Angiography if suspicion of underlying vascular anomaly

Question 13

Treatment of ICH

Answer 13

Surgical evacuation of haematoma +/- treatment of underlying abnormality
Non surgical management

Question 14

What is an intraventricular haemorrhage

Answer 14

Occurs with rupture of a subarachnoid or intracerebral bleed into a ventricle. Any combination of subarachnoid, intracerebral and intraventricular haemorrhage can occur

Question 15

AVM’s

Answer 15

Arterio-venous shunts
Usually intraparenchymal
?congenital
Seizures
Haemorrhage – intracerebral, subarachnoid, subdural
Headache - pulsatile
Steal syndrome - some kind of vascular abnormality steals blood from brain tissue around area - ischaemia - slowly progressing focal neurological deficit

rare
clumps of abnormal blood vessels in brain due to abnormal shunt between artery and vein

can be congenital can be acquired due to faulty regeneration of blood vessels

Question 16

Treatment of AVMs

Answer 16

Surgery - definitive

Endovascular embolisation

Stereotactic radiotherapy - v high single dose gamma irradiation - takes few years to work - slowly obliterates

Conservative

Weigh risks against benefit