Intracranial headbleeds Flashcards
Second most common cause for intracranial hemorrhage
cerebral amyloid angiopathy (CAA)
What is cerebral amyloid angiopathy?
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.
spontaneous lobar ICH presentation
headache, focal deficits, hemiparesis, seizures, AMS
Presentation of cerebral amyloid angiopathy
asymptomatic in most patients may present with transient neuro symptoms (weakness paresthesias) and more commonly symptoms of spontaneous lobar ICH.
Who gets cerebral amyloid angiopathy?
pts >75 yrs with multiple lobar (cortical or subcortical white matter) hemorrhages on brain imaging. Higher rate of occurrance than those w/ hypertensive hemorrhage
AV malformation of ICH happens in what age group
10-40 yrs and extends into ventricles and or subarachnoid space and not limited to lobar area.
Most common cause of ICH
hypertensive hemorrhagic ICH
Where does hypertensive hemorrhagic ICH happen in the brain?
in the putamen followed by the thalamus, pons, and cerbellum (unlike lobar ICH with cerebral amyloid angiopathy)
CNS metastasis resulting in ICH presentation
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
What age group does berry aneurysm happen in?
40-60 yrs old
Presentation of ruptured berry aneurysm?
sudden onset of thunderclap headache, confusion, fever, nuchal rigidity,
CT scan of ruptured berry aneurysm shows:
bleeding within the subarachnoid space as opposed to lobar or intraparenchymal bleeding.
subdural hematoma risk factors
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.
epidural hematoma is a result of
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
epidural hematoma on CT scan
See the CT head with an almond shaped pattern of bleeding
surgical evaluation for anyone who has:
GCS<9
anisocoria
hematoma >30 ML
subdural hematoma on CT scan
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.
who gets a subdural hematoma?
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.
most commonly due to ruptured arterial saccular “berry aneurysm
subarachnoid hemorrhage
severe onset headache at onset of neurological symptoms, meningeal irritation (neck stiffness) focal deficits uncommon
subarachnoid hemorrhage
complications of subarachnoid hemorrhage
rebleeding which happens in 1st 24 hrs vasospasm (after 3 days) hydrocephalus/increased ICP seizures hyponatremia from SIADH
diagnosis of subarachnoid hemorrhage is from
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
Treatment of subarachnoid hemorrhage:
angiographic procedure to stabilize aneurysm by coiling or stenting with endovascular therapy
what helps to prevent vasospasms that occur within 3 days after subarachnoid hemorrhage?
nimodipine and hyperdynamic therapy to reduce vasospasm
severe headache and meningismus think:
subarachnoid hemorrhage
initial step of SAH is to
get conventional angiogram to help do an endovascular approach to stabilize the aneurysm.
what is major cause of death within 1st 24hrs of subarachnoid hemorrhage?
rebleeding mortality for SAH is 10% prior to hospital and 25% within 1st 24 hrs.
acute hypertensive cerebellar hemorrhage can cause
increased intracranial pressure and secondary upward transtentorial herniation
most commonly occurred place for hypertensive hemorrages:
basal ganglia and thalamus can be seen in cerebellum and pons and lobar areas
severe headache, nausea/vomiting, vertigo, unsteadiness, and mental status changes
acute hypertensive cerebellar hemorrhage
increased ICP can cause the cerebellum to herniate and affect
mid brain will see areflexic pupils, impaired oculocephalics and extensor posturing in pt
Cushing’s reflex is:
Sign of increased ICP hypertension, bradycardia, and Cheyes Stokes breathing
compression of medulla oblongata can cause
ataxic breathing, loss of gag and cough reflexes
Where is the lesion?
This is someone who presents with this CT> BLood pressure is 180/110. What to do next?
They have a hemorrhagic stroke with extension to the ventricles.
Lower BP with a IV medication like nicardipine, labetalol or esmolol.
79 y o F with ETOH consumption and falls now has lethargy, confusion and focal weakness. Should be suspicious of
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.
vitamin B deficiency can present with
neuropsychiatric changes and numbness and seen with glossitis and anemia and won’t cause somnolence and focal neurological changes.
When to get surgical evaluation for epidural and subdural hematomas
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.
signs of poor prognosis for subarachnoid hemorrhage
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.
