Neuro5 Intracranial Hemorrhage

Question 1

Epidural hematoma

Answer 1

Rupture of middle meningeal artery (branch
of maxillary artery), often secondary to fracture
of temporal bone. Lucid interval. Rapid
expansion under systemic arterial pressure:
transtentorial herniation, CN III palsy.
CT shows “biconvex disk” not crossing suture
lines. Can cross falx, tentorium

Question 2

Subdural hematoma

Answer 2

Rupture of bridging veins. Slow venous bleeding
(less pressure = hematoma develops over time).
Seen i n elderly individuals, alcoholics, blunt
trauma, shaken baby (predisposing factorsbrain
atrophy, shaking, whiplash). Crescent-shaped hemorrhage that crosses suture lines. Midline shift. Gyri are preserved, since pressure is distributed equally. Cannot cross falx, tentorium

Question 3

Subarachnoid hemorrhage

Answer 3

Rupture of an aneurysm (usually berry aneurysm in Marfan’s, Ehlers-Danlos, ADPKD) or an AVM. Rapid time course. Patients complain of “worst headache of my life.” Bloody or yellow (xanthochromic) spinal tap. 2-3 days afterward, risk of vasospasm due to blood breakdown (not visible on C1

Question 4

lntraparenchymal (hypertensive) hemorrhage

Answer 4

Most commonly caused by systemic hypertension, but also amyloid angiopathy, vasculitis, and neoplasm. Typically occurs in basal ganglia and internal capsule, but can be lobar.

Question 5

Ischemic brain disease

Answer 5

Irreversible damage after 5 minutes. Most vulnerable-hippocampus, neocortex, cerebellum, watershed areas. Irreversible neuronal injury-red neurons ( 12-48 hours) , necrosis + neutrophils (24-72 hours), macrophages (3-5 clays) , reactive gliosis + vascular proliferation (1-2 weeks), glial scar (> 2 weeks) .

Question 6

Atherosclerosis

Answer 6

thrombi lead to ischemic stroke with subsequent necrosis. Form cystic cavity with reactive gliosis

Question 7

Hemorrhagic stroke

Answer 7

Intracerebral bleeding, often clue to hypertension, anticoagulation, and cancer (abnormal vessels can bleed). May be 2° to ischemic stroke followed by reperfusion (increases vessel fragility).

Question 8

Ischemic stroke

Answer 8

Emboli block large vessels; etiologies include atrial fibrillation, carotid dissection, patent foramen ovale, endocarditis. Lacunar strokes block small vessels, may be 2° to hypertension. Treatment: tPA within 4.5 hours (so long as patient presents within 3 hours of onset) .

Question 9

Transient ischemic attack (TIA)

Answer 9

brief, reversible episode of neurologic dysfunction lasting fewer than 24 hours; deficits clue to focal ischemia.

Question 10

Stroke imaging

Answer 10

bright on diffusion-weighted MRI in 3-30 minutes and remains bright for 10 days, dark on noncontrast CT in ~ 24 hours. Bright areas on noncontrast CT indicate hemorrhage (tPA contraindicated) .