Intracranial Hemorrhage

Question 1

Post a SAH, how common is a rebleed?

Answer 1

• 50% risk in 1st 6 MONTHS

- 20% risk in 1st 14 DAYS

Question 2

How to manage rebleeds?

Answer 2

• with surgical clipping

- endovascular tech.

Question 3

Complications of SAH?

Answer 3

Re-bleeding
Delayed ischaemic neurological deficit
Hydrocephalus
Hyponatraemia
Seizures

Question 4

When does DIND set in and why?

Answer 4

• in days 3-12 post SAH

- d.t large vessel vasospasm

Question 5

How to manage DIND?

Answer 5

• –serial neurological examination post-SAH; checking for deterioration of neurological symptoms
• NIMODIPINE
• high fluid intake (Triple H therapy)

Question 6

How does hydrocephalus present as?

Answer 6

• 6% is symptomatic
• incr. headache/ altered conscious
• transient

Question 7

How to manage Hydrocephalus?

Answer 7

• CSF drainage
• LP
• EVD shunt (ventriculostomy)

Question 8

How does hyponatremia occur post-SAH?

Answer 8

• d.t SIADH
• Cerebral salt wasting
• acute cortisol insufficiency
• excessive IV fluid therapy
• diuretic therapy

Question 9

How to manage hyponatremia post-SAH?

Answer 9

• do not fluid restrict
• supplement sodium intake
• fludrocortisone

Question 10

How freq. are seizures post-SAH?

Answer 10

• 10% risk in 5years
• – 3% ACUTE risk
• —-rx: anti-convulsant prophylaxis

Question 11

How to manage SAH?

Answer 11

• bed rest
• Nimodipine (to prevent vasospasm> DIND)
• anti-emetics
• IV fluids
• Analgesia

Question 12

What % of SAH pts die in the first month?

Answer 12

50% !

Question 13

Are SAH survivors left with disability?

Answer 13

YES

- 50% of them

Question 14

50% of intracerebral hemmorhage is d.t _____

Answer 14

-hypertension

Question 15

30% of intracerebral hemorrhage is d.t ________

Answer 15

AVMs or Aneurysm

Question 16

Which anatomical structure of the brain is predisposed to intracerebral hemorrhage IIary to hypertension?

Answer 16

• Basal Ganglia

- —d.t Charcot-Bouchard Microaneurysms

Question 17

Where the CB microaneurysms arise from?

Answer 17

• in SMALL perforating arteries seen in the BASAL ganglia

Question 18

How does ICH present as?

Answer 18

• headache
• focal neurological deficit
• decr. conscious level

Question 19

What ivx can be performed for ICH?

Answer 19

CT scan (fast for LOC) 
Angiography (for suspected vascular anomaly)

Question 20

How to treat ICH?

Answer 20

• surgical evacuation of HEMATOMA (+/- underlying abnormality)
• non-surgical management

Question 21

When is ICH a good prognosis?

Answer 21

• when the hematoma is SUPERFICIAL and SMALL

- and there is GOOD neurological status

Question 22

When does ICH pt have poor prog?

Answer 22

• if the hematoma is LARGE, in the basal ganglia or thalamus
• —causing MAJOR focal deficit/ COMA

Question 23

What ruptures in intraventricular hemorrhage?

Answer 23

• rupture of subarachnoid vessel
  OR
• the intracerebral bleed is into the ventricles

Question 24

What are AVMs?

Answer 24

• arterio-venous shunts
• —intraparenchymal
• could be CONGENITAL

Question 25

How are AVMs treated?

Answer 25

• surgery
• endovascular embolisation
• stereotactic radiotherapy
• conservative

Question 26

List the 3 causes of spontaneous intracranial hemorrhage.

Answer 26

AVM
Aneurysm
Hypertension

Question 27

What are other causes of spontaneous intracranial hemorrhage?

Answer 27

• bleeding diatheses
• tumors
• drugs (warfarin/ heparin)
• —factors relevant post trauma

Question 28

What is STEAL syndrome?

Answer 28

AVMs siphons blood from near by blood vessels; resulting in eventual formation of aneurysms over time.

–> may RUPTURE over time !