Intracranial headbleeds

Question 1

Second most common cause for intracranial hemorrhage

Answer 1

cerebral amyloid angiopathy (CAA)

Question 2

What is cerebral amyloid angiopathy?

Answer 2

infiltration of cerebral blood vessels with abnormal beta pleated sheet protein (amyloid)

causes blood vessels to lose their natural elasticity and become more fragile and bleed easily.

Question 3

spontaneous lobar ICH presentation

Answer 3

headache, focal deficits, hemiparesis, seizures, AMS

Question 4

Presentation of cerebral amyloid angiopathy

Answer 4

asymptomatic in most patients may present with transient neuro symptoms (weakness paresthesias) and more commonly symptoms of spontaneous lobar ICH.

Question 5

Who gets cerebral amyloid angiopathy?

Answer 5

pts >75 yrs with multiple lobar (cortical or subcortical white matter) hemorrhages on brain imaging. Higher rate of occurrance than those w/ hypertensive hemorrhage

Question 6

AV malformation of ICH happens in what age group

Answer 6

10-40 yrs and extends into ventricles and or subarachnoid space and not limited to lobar area.

Question 7

Most common cause of ICH

Answer 7

hypertensive hemorrhagic ICH

Question 8

Where does hypertensive hemorrhagic ICH happen in the brain?

Answer 8

in the putamen followed by the thalamus, pons, and cerbellum (unlike lobar ICH with cerebral amyloid angiopathy)

Question 9

CNS metastasis resulting in ICH presentation

Answer 9

acute as there could be hemorrhage into tumor; generally will have symptoms of headache and focal deficits and seizures related to mass effect of tumor

Question 10

What age group does berry aneurysm happen in?

Answer 10

40-60 yrs old

Question 11

Presentation of ruptured berry aneurysm?

Answer 11

sudden onset of thunderclap headache, confusion, fever, nuchal rigidity,

Question 12

CT scan of ruptured berry aneurysm shows:

Answer 12

bleeding within the subarachnoid space as opposed to lobar or intraparenchymal bleeding.

Question 13

subdural hematoma risk factors

Answer 13

history of ETOH use, older age and trauma results from tearing of bridging veins and see bleeding into the space between arachnoid membranes and dura.

Question 14

epidural hematoma is a result of

Answer 14

secondary to arterial bleeds and will present with a lucid interval after head trauma.

laceration of middle meningeal artery from the temporal bone fracture

See the CT head - almond shaped pattern of bleeding

Question 15

epidural hematoma on CT scan

Answer 15

See the CT head with an almond shaped pattern of bleeding

surgical evaluation for anyone who has:

GCS<9

anisocoria

hematoma >30 ML

Question 16

subdural hematoma on CT scan

Answer 16

See a crescent like pattern of bleeding - pathognomonic for subdural hematoma

in chronic subdural hematoma - can see crescent shaped extra axial lesion. won’t light up as white.

Question 17

who gets a subdural hematoma?

Answer 17

25% of cases are elderly. need to get a CT scan

from rupture of bridging veins in the brain and dura mater. THis is from anticoagulation or truama or spontaneously occurrence.

Question 18

most commonly due to ruptured arterial saccular “berry aneurysm

Answer 18

subarachnoid hemorrhage

Question 19

severe onset headache at onset of neurological symptoms, meningeal irritation (neck stiffness) focal deficits uncommon

Answer 19

subarachnoid hemorrhage

Question 20

complications of subarachnoid hemorrhage

Answer 20

rebleeding which happens in 1st 24 hrs vasospasm (after 3 days) hydrocephalus/increased ICP seizures hyponatremia from SIADH

Question 21

diagnosis of subarachnoid hemorrhage is from

Answer 21

non contrast CT >90% sensitive lumbar puncture is required to definitely rule out SAH- see xanthrochromia in CSF (seen about 6 hrs after) Cerebral angiograph to identify bleeding source

Question 22

Treatment of subarachnoid hemorrhage:

Answer 22

angiographic procedure to stabilize aneurysm by coiling or stenting with endovascular therapy

Question 23

what helps to prevent vasospasms that occur within 3 days after subarachnoid hemorrhage?

Answer 23

nimodipine and hyperdynamic therapy to reduce vasospasm

Question 24

severe headache and meningismus think:

Answer 24

subarachnoid hemorrhage

Question 25

initial step of SAH is to

Answer 25

get conventional angiogram to help do an endovascular approach to stabilize the aneurysm.

Question 26

what is major cause of death within 1st 24hrs of subarachnoid hemorrhage?

Answer 26

rebleeding mortality for SAH is 10% prior to hospital and 25% within 1st 24 hrs.

Question 27

acute hypertensive cerebellar hemorrhage can cause

Answer 27

increased intracranial pressure and secondary upward transtentorial herniation

Question 28

most commonly occurred place for hypertensive hemorrages:

Answer 28

basal ganglia and thalamus can be seen in cerebellum and pons and lobar areas

Question 29

severe headache, nausea/vomiting, vertigo, unsteadiness, and mental status changes

Answer 29

acute hypertensive cerebellar hemorrhage

Question 30

increased ICP can cause the cerebellum to herniate and affect

Answer 30

mid brain will see areflexic pupils, impaired oculocephalics and extensor posturing in pt

Question 31

Cushing’s reflex is:

Answer 31

Sign of increased ICP hypertension, bradycardia, and Cheyes Stokes breathing

Question 32

compression of medulla oblongata can cause

Answer 32

ataxic breathing, loss of gag and cough reflexes

Question 33

Where is the lesion?

Answer 33

Question 34

This is someone who presents with this CT> BLood pressure is 180/110. What to do next?

Answer 34

They have a hemorrhagic stroke with extension to the ventricles.

Lower BP with a IV medication like nicardipine, labetalol or esmolol.

Question 35

79 y o F with ETOH consumption and falls now has lethargy, confusion and focal weakness. Should be suspicious of

Answer 35

chronic sudural hematoma.

• Acute SDH- seen with coma in 50% of cases after a transient “lucid” interval followed by rapid neurological decline.

-Chronic SDH- seen in elderly nd ETOH absue presents with insidious onset of more global deficits like:

headaches, lightheadedness, cognitive impairment, and personality changes and somnolence.

Focal deficits like leg weakness are rare but can occur ipsilateral or contralateral to head bleed

Symptoms can present weeks after initial trauma and may fluctuate and diagnosis isvia the axial lesion on CT head.

Question 36

vitamin B deficiency can present with

Answer 36

neuropsychiatric changes and numbness and seen with glossitis and anemia and won’t cause somnolence and focal neurological changes.

Question 37

When to get surgical evaluation for epidural and subdural hematomas

Answer 37

epidural hematoma- almond shaped - middle menigeal artery laceration

• GCS <9, anisocoria (asymmetric pupil), or hematoma >30 ml on CT

Sudural hematoma - crescent shape- bridging vein ruptures

• hematoma thickness >10 mm, GCS<9, and presence of pupillary asymmetry or fixation

In chronic hematomas - a hematoma >10 mm and midline shift greater than 5mm or significant neurolgoical compromise needs drainage.

Question 38

signs of poor prognosis for subarachnoid hemorrhage

Answer 38

ICP signs leads to deterioration in consciousness with signs of confusion, lethargy, and eventual stupor and coma which may be result of motor weakness and sensory deficits due to cerebral and brainstem compression.

poor prognostic sign is Cushing’s triad with bradycardia, HTN with widening pulse pressure and irregular respirations.