Neurology - Intracranial Bleeds Flashcards
List the types of intracranial haemorrhage
- Extradural haemorrhage
- Subdural haemorrhage
- Intracerebral haemorrhage
- Subarachnoid haemorrhage
What percentage of strokes do intracerebral and subarachnoid haemorrhages account for?
10-20%
List risk factors for intracranial bleeding
Head injuries
Hypertension
Aneurysms
Ischaemic strokes
Brain tumours
Thrombocytopenia
Bleeding disorders
Anticoagulants e.g. DOACs or Warfarin
How do intracranial haemorrhages present?
- Sudden-onset headache
- Seizures
- Vomiting
- Reduced consciousness
- Focal neurological symptoms e.g. weakness
What is GCS scored out of?
15
How do you remember the 3 different scores of GCS?
EYES
4 letters so out of 4
Mouth (speech)
5 letters so out of 5
Muscle(motor)
6 letters so out of 6
What are the different scores for eyes?
EYES
Out of 4
1-No response
2- Pain
3- Speech
4- Normal
What are the different scores for verbal response?
Mouth
Out of 5
1-No response
2-Just sounds
3-Just words
4-Confused
5-Normal
What are the different scores for motor response?
Muscle
Out of 6
1-No response
2-Abnormal extension (e before f- alphabetical)
3-Abnormal flexion
4-Moves from pain
5-Moves to pain
6-Normal
A 30 year old adult comes into A & E after a crash. What is his GCS?
13
Eyes
3- opens to speech
Mouth
4- can talk but confused
Muscle
6
28-year-old man is brought to A&E with a reduced level of consciousness. What is his GCS?
7
Eyes
2-opens to pain
Mouth
2- only sounds not words
Muscle
3-e before f, flexion is 3
A patient is brought into A&E following an accident. What is his GCS?
13- Scored with best response
Eyes
3- to speech
Mouth
4- He is confused
Muscle
6- Can follow commands even if intermittently
A 67-year old female presents to A&E unconscious after falling down a flight of stairs. What is her GCS score?
8
Eyes
2- Responds to pain
Mouth
3- Words not sounds
Muscle
3-e before f, flexion is 3
A 30 year old adult comes into A&E after a car accident. What is his GCS?
7
Eyes
1- Cannot open
Mouth
4- Confused
Muscle
2- Extension, e before f, so 2
88-year old female presents to A&E unconscious after being hit by a bicycle. What is her GCS?
6
Eyes
2-response to pain
Mouth
2-just sounds
Muscle
2–extension, e before f, 2
Where do extradural haemorrhages occur?
Between the skull and dura
Usually caused by Middle Meningeal Artery rupture associated with temporal bone
How do extradural haemorrhages present on CT?
Bi-convex shape (lemon)
This is because the blood in an extradural is unable to cross cranial sutures
How do extradurals present?
Young patient with traumatic head injury and ongoing headache
Period of normality then rapid decline
The haematoma becomes large enough to compress intracranial contents
Where do subdural haematomas occur?
Between dura and arachnoid mater
Subdural
Bridging veins
Banana shape (crescent)
Not limited by cranial sutures as it occurs under the dural layer
Who is typically affected by subdural haemorrhages?
Elderly and alcholic patients
Increased brain atrophy, vessels are more fragile and rupture more easily
What is an intracerebral haemorrhage?
Bleeding in the brain tissue
How do intracerebral haemorrhages present?
Sudden-onset focal neurological symptoms
- Limb weakness
- Facial weakness
- Dysphasia
- Vision loss
Can occur spontaneously or secondary to ischaemic stroke, tumours or aneurysm rupture
Where can intracerebral heamorrhages occur?
Anywhere in the brain tissue e.g.
Lobar
Deep
Intraventricular
Basal ganglia
Cerebellar
Where do subarachnoid haemorrhages occur?
Between the pia and arachnoid mater
Usually due to ruptured cerebral aneurysm
What is the mortality risk of a SAH?
30%
Who is more commonly affected by SAHs?
45-70
Women
Black
What are the some risk factors for SAHs?
General risk factors
- Hypertension
- Smoking
- Excessive alcohol intake
Associations
- Family history
- Cocain use
- Sickle cell anaemia
- Connective tissue disorders (Marfan’s or Ehlers-Danlos)
- Neurofibromatosis
- Autosomal dominant PKD
How do SAHs present?
Sudden-onset occipital headache during strenuous activity e.g.
- Heavy lifting
- Sex
Feeling of being hit at the back of the head
- Neck stiffness
- Photophobia
- Vomiting
- Neurological symptoms
Sudden and severe onset - thunderclap headache description
What investigations are used for a SAH?
CT head is first line
- Less reliable after 6 hours
Lumbar puncture
- Considered after a normal CT head
- Wait at least 12 hours after symptoms as it takes time for bilirubin to accumulate in the CSF
CSF will show:
- Xanthochromia (yellow colour due to bilirubin)
- Raised red cell count
CT angiography
Confirm bleeding source
How do SAHs present on CT?
Starsign
How are SAHs managed?
Specialist neurosurgical unit, may need ICU in reduced consciousness
Surgical intervention
- Treat the aneurysm, repair vessel and prevent re-bleeding
Done by endovascular coiling
(platinum coils placed in aneurysm by EVAR to seal aneurysm from artery)
Neurosurgical clipping
What is used to prevent vasospasm in SAHs?
Nimodipine
Vasospasm is common after a SAH and causes brain ischaemia
What are some potential complications of a SAH?
Hydrocephalus
- LP
- External ventricular drain (drains CSF)
- Ventriculoperitoneal shunt (conencts ventricles with peritoneal cavity)
Seizures
- Anti-epileptics
What are the general principles of managing an intracranial bleed?
Immediate imaging
CT head - establish diagnosis
FBC - look at platelets
Coagulation screen - look for bleeding disorders
How are intracranials managed?
- Admission to specialist stroke centre
- Consider surgical treatment
- Intubation, ventilation and ICU if reduced conscioussness
- Correct clotting abnormalities
- Correct hypertension, avoid hypotension
Smaller bleeds can be managed conservatively and repeat imaging
What are the surgical options for an extradural or subdural haematoma?
Craniotomy
Burr holes to drain blood
