Neurology: Bleeds Flashcards
What are some differentials for Raised Intracranial Pressure?
- Space Occupying Lesion
- Idiopathic Intracranial Hypertension
- Venous Sinus Thrombosis
- Hydrocephalus
- Meningitis (bacterial/viral/fungal)
- Intracerebral haemorrhage
- Malignant oedema
- Hydrocephalus
- Haematoma Expansion
What are symptoms and signs of Raised intracranial pressure?
- Headache: on waking, inc. or assess with visual obscuration with valsalva, bending etc
- Papilledema
- Vomiting
- Respiratory changes: periodic breathing, apnoea
- False localising signs eg VI palsy
- Bradycardia
- Increased BP
- Fever and Leucocytosis then look for ear, nose infections preceding headache
What are investigations of Raised Intracranial Pressure?
- CT brain
- MRI brain
- Magnetic Resonance Venography – thrombosis
- Sinus X-rays - consider if signs of nose and ear infections
What are symptoms of Space Occupying Lesion?
-
Deep, aching, dull pain.
- Due to traction on pain sensitive structures e.g. blood vessels, dura, RICP. More likely pain with fast expanding lesions
What is the typical patient type in idiopathic intracranial hypertension?
- Obese young women
What are symptoms and signs of Idiopathic Intracranial Hypertension?
Symptoms
- Headache
- Blurred vision; enlarged blind spot
- 6th nerve palsy may be present
Signs
- Papilloedema usually present
- Raised ICP but absence of intracranial mass or ventricular dilatation
What is the investigations for idiopathic intracranial hypertension?
- Lumbar puncture has higher opening pressure (normal 5-25 cmH2O)
- Normal CSF composition
- Normal neurological examination except papilledema (occasional 6th nerve palsy)
What is the management for idiopathic intracranial hypertension?
Lifestyle
- Weight Loss
Medications
- Acetazolamide: carbonic anhydrase inhibitor
- Topiramate: added benefit of causing weight loss in most patients
- Diuretics
Surgical
- Urgent LP
- Optic nerve sheath fenestration
- Shunts
What are symptoms for venous sinus thrombosis?
- Headache
- Papilledema
- Reduced consciousness
- Seizures
- Focal neurological signs
What is a Subarachnoid Haemorrhage?
- Bleeding into the subarachnoid space which anatomically exists between the arachnoid mater and pia mater
- Typical patients around 60 years old and accounts for 3% of all strokes
What are Berry Aneurysms?
- Occur at Bifurcations of Arteries.
- Typically saccular aneurysms that occur mostly at either the Circle of Willis or Bifurcation of the Middle Cerebral Artery
- Present 3% of adult population unruptured. Ruptured aneurysm present in 40—60 olds and can cause either subarachnoid haemorrhages, cerebral haematoma or interventricular haemorrhage
What are risk factors of Subarachnoid Haemorrhage?
- Family history
- Female Gender
- African descent
What are causes of Subarachnoid Haemorrhage?
- Autosomal Dominant Polycystic Kidney Disease (Fibromuscular Dysplasia, Connective Tissue Disorders, Atherosclerosis, Hypertension)
- Trauma
- Arteriovenous malformations
- Coagulopathies
- Tumour related
What are differentials for Subarachnoid Haemorrhage?
- Migraine: short time to maximal headache intensity and presence of neck stiffness indicates SAH
- Call-Fleming Syndrome: also has thunderclap headache
- Acute Bacterial Meningitis: abrupt headache if meningeal micro-abscess ruptures
- Cervical Arterial Dissection: present with sudden headache
What are symptoms of Subarachnoid Haemorrhage?
- Sudden, very severe headache often occipital
- Nausea and Vomiting often follows headache
- Neck stiffness
- Reduced consciousness
- Collapse or seizure
- Coma and Death
What are investigations for Subarachnoid Haemorrhage?
Initial
- Urgent non contrast CT head
- Hyperattenuating material in the subarachnoid space.
- Lumbar puncture
- Not necessary if SAH confirmed by CT but performed if there is doubt
- CSF become yellow (xanthochromic) within 12 hours of SAH and remains detectable for 2 weeks
- Visual inspection of supernatant CSF is usually sufficiently reliable for diagnosis.
- Spectrophotometry is used to estimate bilirubin in the CSF release from lysed cells is used to define SAH with certainty.
Definitive
- CT angiography or digital subtraction angiography
- Used to identify aneurysm or other source of bleeding performed in patients potentially fit for surgery
What is the immediate management for a Subarachnoid haemorrhage?
Immediate
- A to E approach with fluid resuscitation and analgesia with anti-emetics as necessary
- Early neurosurgical involvement and transfer to high dependency unit
- Bed rest and supportive measures
What are medical and surgical management for Subarachnoid Haemorrhage?
Medical
- Nimodipine – calcium channel blocker with aims to reduce vasospasm and reduce risk of delayed cerebral ischaemia
Surgical Management
- Neurosurgical intervention with either coiling or clipping of the aneurysm depending on the location, size, age and comorbidities
- 80% are coiled – requires suitable neck to dome ratio. More suitable in presence of multiple co-morbidities, older patient age, presence of vasospasm or aneurysm present in deep areas or along basilar artery
- Clipping on minority – mainly if morphology of aneurysm is not suitable for coiling, presence of clot or previously coiled aneurysm that ruptured
What are ongoing monitoring and management techniques used for Subarachnoid Haemorrhages?
- Monitor for potential complications
- ICP monitoring may be required
- Prophylactic levetiracetam may be started to reduce seizure risk
What are complications of Subarachnoid Haemorrhage?
- Obstructive hydrocephalus
- Vasospasm
- Electrolyte disturbance
- Coma
- Hemiparesis
- Rebleeding
What is the definition of Subdural Haemorrhage?
- Subdural haematoma is a collection of blood between inner layer of dura and the arachnoid mater
- It is an ‘extra-axial’ or ‘extrinsic’ lesion which could be unilateral or bilateral
What are classifications of Subdural Haemorrhage?
Subdural haematomas can be classified in terms of their age:
- Acute
- Subacute
- Chronic
Although the collection of blood is within the same anatomical compartment, acute and chronic subdurals have important differences in terms of their mechanisms, associated clinical features and management:
What is the causes of acute subdural haematoma?
Acute
- Collection of fresh blood within the subdural space and is most commonly caused by high-impact trauma. Since it is associated with high-impact injuries, there is often other brain underlying brain injuries.
What are symptoms and presentations of acute subdural haematoma?
- Depends on the size of the compressive acute subdural haematoma and the associated injuries.
- Presentation ranges from an incidental finding in trauma to severe coma and coning due to herniation
What are investigations of Acute Subdural haematoma?
CT imaging is the first-line investigation
- Shows crescentic collection, not limited by suture lines.
- They will appear hyperdense (bright) in comparison to the brain.
- Large acute subdural haematomas will push on the brain (‘mass effect’) and cause midline shift or herniation
What is the management of Acute Subdural Haematoma?
- Small or incidental acute subdurals can be observed conservatively.
- Surgical options include monitoring of intracranial pressure and decompressive craniectomy.
What are causes of Chronic Subdural Haematoma?
- Collection of blood within the subdural space that has been present for weeks to months.
- Rupture of the small bridging veins within the subdural space rupture and cause slow bleeding. Elderly and alcoholic patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taut bridging veins.
- Infants also have fragile bridging veins and can rupture in shaken baby syndrome.
What are the presentations of Chronic Subdural Haematoma?
Several week to month progressive history of either
- Confusion
- Reduced consciousness
- Neurological deficit.
What are investigations for Chronic Subdural Haemorrhage?
CT imaging
- Crescentic in shape, not restricted by suture lines and compress the brain (‘mass effect’).
- In contrast to acute subdurals, chronic subdurals are hypodense (dark) compared to the substance of the brain.
What is the management of Chronic Subdural Haemorrhage?
- If the chronic subdural is an incidental finding or if it is small in size with no associated neurological deficit then it can be managed conservatively with the hope that it will dissolve with time.
- If the patient is confused, has an associated neurological deficit or has severe imaging findings then surgical decompression with burr holes is required
What is Cavernous Sinus Syndromes?
Thrombosis of dural venous sinuses such as sagittal sinus causes raised intracranial pressure with headache, papilledema and frequently seizures which may progress to coma
What are symptoms of Cavernous Sinus Syndromes?
- Eye pain
- Fever
- Proptosis
- Chemosis
- External and internal ophthalmoplegia with papilledema
What is the management of Cavernous Sinus Syndomes?
- MRI and MR venography shows occluded sinuses and/or veins
- Treatment is with heparin initially followed by warfarin or other oral anticoagulants for 6 months
- Anticonvulsants are given if necessary
What are signs of Subarachnoid Haemorrhage?
- Positive Kernig’s sign - when thigh is flexed at the hip and knee at 90-degree angles, extension of the knee is painful
- Papilledema is sometimes present with retinal and/or subhyaloid haemorrhage
