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Year 4 - Neurology and Special Senses > Neurology - Intracranial Bleeds > Flashcards

Neurology - Intracranial Bleeds Flashcards

1
Q

List the types of intracranial haemorrhage

A
  • Extradural haemorrhage
  • Subdural haemorrhage
  • Intracerebral haemorrhage
  • Subarachnoid haemorrhage
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2
Q

What percentage of strokes do intracerebral and subarachnoid haemorrhages account for?

A

10-20%

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3
Q

List risk factors for intracranial bleeding

A

Head injuries
Hypertension
Aneurysms
Ischaemic strokes
Brain tumours
Thrombocytopenia
Bleeding disorders
Anticoagulants e.g. DOACs or Warfarin

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4
Q

How do intracranial haemorrhages present?

A
  • Sudden-onset headache
  • Seizures
  • Vomiting
  • Reduced consciousness
  • Focal neurological symptoms e.g. weakness
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5
Q

What is GCS scored out of?

A

15

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6
Q

How do you remember the 3 different scores of GCS?

A

EYES
4 letters so out of 4

Mouth (speech)
5 letters so out of 5

Muscle(motor)
6 letters so out of 6

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7
Q

What are the different scores for eyes?

A

EYES
Out of 4

1-No response
2- Pain
3- Speech
4- Normal

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8
Q

What are the different scores for verbal response?

A

Mouth
Out of 5

1-No response
2-Just sounds
3-Just words
4-Confused
5-Normal

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9
Q

What are the different scores for motor response?

A

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

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10
Q

A 30 year old adult comes into A & E after a crash. What is his GCS?

A

13

Eyes
3- opens to speech

Mouth
4- can talk but confused

Muscle
6

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11
Q

28-year-old man is brought to A&E with a reduced level of consciousness. What is his GCS?

A

7

Eyes
2-opens to pain

Mouth
2- only sounds not words

Muscle
3-e before f, flexion is 3

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12
Q

A patient is brought into A&E following an accident. What is his GCS?

A

13- Scored with best response

Eyes
3- to speech

Mouth
4- He is confused

Muscle
6- Can follow commands even if intermittently

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13
Q

A 67-year old female presents to A&E unconscious after falling down a flight of stairs. What is her GCS score?

A

8

Eyes
2- Responds to pain

Mouth
3- Words not sounds

Muscle
3-e before f, flexion is 3

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14
Q

A 30 year old adult comes into A&E after a car accident. What is his GCS?

A

7

Eyes
1- Cannot open

Mouth
4- Confused

Muscle
2- Extension, e before f, so 2

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15
Q

88-year old female presents to A&E unconscious after being hit by a bicycle. What is her GCS?

A

6

Eyes
2-response to pain

Mouth
2-just sounds

Muscle
2–extension, e before f, 2

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16
Q

Where do extradural haemorrhages occur?

A

Between the skull and dura

Usually caused by Middle Meningeal Artery rupture associated with temporal bone

17
Q

How do extradural haemorrhages present on CT?

A

Bi-convex shape (lemon)

This is because the blood in an extradural is unable to cross cranial sutures

18
Q

How do extradurals present?

A

Young patient with traumatic head injury and ongoing headache

Period of normality then rapid decline

The haematoma becomes large enough to compress intracranial contents

19
Q

Where do subdural haematomas occur?

A

Between dura and arachnoid mater

Subdural
Bridging veins
Banana shape (crescent)

Not limited by cranial sutures as it occurs under the dural layer

20
Q

Who is typically affected by subdural haemorrhages?

A

Elderly and alcholic patients

Increased brain atrophy, vessels are more fragile and rupture more easily

21
Q

What is an intracerebral haemorrhage?

A

Bleeding in the brain tissue

22
Q

How do intracerebral haemorrhages present?

A

Sudden-onset focal neurological symptoms
- Limb weakness
- Facial weakness
- Dysphasia
- Vision loss

Can occur spontaneously or secondary to ischaemic stroke, tumours or aneurysm rupture

23
Q

Where can intracerebral heamorrhages occur?

A

Anywhere in the brain tissue e.g.
Lobar
Deep
Intraventricular
Basal ganglia
Cerebellar

24
Q

Where do subarachnoid haemorrhages occur?

A

Between the pia and arachnoid mater

Usually due to ruptured cerebral aneurysm

25
Q

What is the mortality risk of a SAH?

A

30%

26
Q

Who is more commonly affected by SAHs?

A

45-70
Women
Black

27
Q

What are the some risk factors for SAHs?

A

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

28
Q

How do SAHs present?

A

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

29
Q

What investigations are used for a SAH?

A

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

30
Q

How do SAHs present on CT?

A

Starsign

31
Q

How are SAHs managed?

A

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

32
Q

What is used to prevent vasospasm in SAHs?

A

Nimodipine

Vasospasm is common after a SAH and causes brain ischaemia

33
Q

What are some potential complications of a SAH?

A

Hydrocephalus
- LP
- External ventricular drain (drains CSF)
- Ventriculoperitoneal shunt (conencts ventricles with peritoneal cavity)

Seizures
- Anti-epileptics

34
Q

What are the general principles of managing an intracranial bleed?

A

Immediate imaging

CT head - establish diagnosis

FBC - look at platelets
Coagulation screen - look for bleeding disorders

35
Q

How are intracranials managed?

A
  • 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

36
Q

What are the surgical options for an extradural or subdural haematoma?

A

Craniotomy
Burr holes to drain blood

Year 4 - Neurology and Special Senses (41 decks)

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