Neuro - Extradural and Subdural haemorrhage, SAH, IVT and GCA Flashcards
What is a extradural haemorrhage?
- Usually caused by rupture of middle meningeal artery in temporo-parietal region.
- Can be associated with fracture of the temporal bone
- Arterial blood pills between skull and dura matter - CT shows bi-convex sharped limited to cranial sutures
Why must you be cautious of lucid intervals in patients with suspected brain bleeds?
- Classic history of a young patient with a traumatic head injury with ongoing headache.
- They have a period of improved neurological symptoms and consciousness followed by a rapid developed over hours as the haematoma grows and compresses intracranial contents
What is a subdural haemorrhage? Which patients are most at risk?
- Caused by rupture of bridging veins - venous blood pools between rural and arachnoid matter
- CT: crescent shape - not limited by the cranial sutures
- Frequently seen in elderly and/or alcoholic patients: brain atrophy causes vessels more likely to rupture
Describe other areas of the brain (excluding extra/subdural and SAH) which can have bleeds
- Lobar intracerebral haemorrhage
- Deep intracerebral haemorrhage
- Intraventricular haemorrhage
- Basal ganglia haemorrhage
- Cerebellar haemorrhage
What are the causes of SAH?
Arterial bleed
- Berry aneurisms: 70%
- AVM: 10%
- HTN: 10%
- Idiopathic: 5%
- trauma
What imaging should you perform if you suspect SAH and when should you do it? What other investigation should you perform?
Plain CT
- 90% sensitivity within 24h (but not too early!)
- 50% sensitivity by 72h
LP
-Patients with convincing Hx of SAH should have an LP within 12h of onset - CFS will be analysed for bilirubin (cannot be done too early b/c the RBCs of the haemorrhage cannot be distinguished form trauma of tap RBCs)
What is the management for a patient with SAH?
- Immediate transfer to interventional neuroradiologist/neurosurgical ward for cerebral angiogram and prevention of rebleed
- Nimodipine: prevents cerebral vasospasm caused by blood irritation
- Embolisation of aneurism
- Maintain hydration and BP <150mmHg
- Neuro obs: if pt deteriorates they need urgent CT to rule out hydrocephalus and assess need for CSF shunt/vascular coiling
- If left untreated: 50% of pts will die from sudden raised ICP caused by rebleed and toxic effect on brain parenchyma
What is temporal arteritis?
- Inflammation of walls of medium and larger arteries, branches of carotid artery and ophthalmic artery.
- Leads to headache, visual disturbance (amaurosis fugax) and jaw claudication
What condition is GCA associated with?
Polymyalgia rheumatica
What is the management of GCA?
- Patient should see rheumatologist within same day of presentation
- High dose oral prednisolone - eg 60mg OD +PPI + osteoporosis cover
- Bloods: FBC, LFT, CRP/ESR
- Ophthalmology review
- Temporal and axillary artery US +/- temporal artery biopsy
- May need to take steroids for 1-2 years - must discuss this with patient and address steroid induced SEs
What is intracranial venous thrombosis? Name the main locations where they are found
-Presence of clot in the rural venous sinuses, which drain blood from the brain
Can be found in:
- Sagittal sinus
- Cavernous sinus
- Lateral sinus
What are some symptoms of sagittal sinus thrombosis?
- May present with seizures and hemiplagia
- Parasagittal bipareital or bifrontal haemorrhagic infarctions sometimes seen
What are some symptoms of cavernous sinus thrombosis? What are other causes of cavernous sinus syndrome?
Symptoms
- Periorbital oedema
- Ophthalmoplegia: 6th nerve damage usually occurs before 3rd and 4th because it is located more medially
- Trigeminal nerve involvement: hyperaesthesia of upper face and eye pain
- Central retinal vein thrombosis
What are the features of lateral sinus thrombosis?
-6th and 7th cranial nerve palsies
