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Surgical Emergencies > SAH - Subarachnoid Hemorrhage + others > Flashcards

SAH - Subarachnoid Hemorrhage + others Flashcards

1
Q

What is the typical presentation of a patient with Subarachnoid hemorrhage?

A

Abrupt severe headaches - Worst headache of my life
Nausea and vomiting (increased ICP)
LOC, confusion, drowsy
Neck stiffness and photophobia
+/- focal neurological deficit (variable

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2
Q

What is dysmetria

A

inability to control distance, speed, and range of motion necessary to perform smoothly coordinated movements

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3
Q

What are cerebellar neurological signs?

A

Hypotonia
Nystagmus
Intention tremor
dysdiadokinesia
rebound
Dysmetria

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4
Q

What is hemiparesis?

A

muscle weakness on one side (opposite)

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5
Q

what is hemianesthesia?

A

loss of sensation on one side (opposite)

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6
Q

What are some possible clinical exam findings in subarachnoid hemorrhage (or any brain bleed)

A

!!!Papilloedema!!!
Cranial nerves (blindness - II, movement -III&VI)
Cerebellar signs (hypotonia, nystagmus…)
Hemiparesis (of opposite side)
Hemianaesthesia

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7
Q

What is the first-line DVT prophylaxis?

A

TED stockings

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8
Q

a 35 year old male with no previous history presents by ambulance to the ED with:
Abrupt severe headaches
nausea and vomiting
collapsed, LOC for 10 minutes witnessed by wife
Confused and drowsy
Neck stiffness and photophobia
No focal neurological deficits
What is your ddx? Most likely diagnosis?
What is your initial investigation?
What is your immediate management?

A

Most likely: SAH
Ddx: Other brain bleed, stroke, meningitis, migraine

Initial investigation: Non-contrast CT brain
Initial management: ABC (vitals, O2, wide bore, NPO) + + Analgesia (paracetamol + codeine or Morphine) + DVT prophylaxis (TED stockings)

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9
Q

Non-contrast CT brain must be conducted as soon as possible from time of insult as sensitivity diminishes with time where 90% of lesions can be detected after 1st day and 50% after first week. Why is non-contrast CT performed over contrast? What findings on a non-contrast CT brain would be consistent with Subarachnoid hemorrhage?

A

Risk of hemorrhage where contrast would leak as well as a potential hemorrhagic stroke.
Highly attenuated material (bright) in
1) Sulci
2) Fissures
3) Ventricles
4) Base of brain
Note: you will see tracks in the sulci and fissures

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10
Q

A non-contrast CT is not available in the hospital as the CT machine is under emergency repair. What is an alternative method of diagnosis of SAH? What do you expect to find to confirm the diagnosis?

A

Lumbar Puncture (L4/L5) showing RBC or Xanthochromia

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11
Q

What is Xanthochromia in CSF?

A

yellow discoloration of CSF (should be clear) due to Hb catabolism

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12
Q

SAH occur between which meninges?

A

Between arachnoid and pia mater

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13
Q

Where is CSF usually found?

A

Ventricles and cranial + spinal subarachnoid space

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14
Q

What is the most common cause of SAH?

A

Aneurysm (85% of non-traumatic)

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15
Q

A complication of what other brain bleeds is SAH?

A

Intraparenchymal or intraventricular hemorrhages can extend into subarachnoid space

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16
Q

What are the causes of SAH?

A

Traumatic
Non-traumatic: Aneurysm (85%), AV malformations, Extension of intraparenchymal or intraventricular hemorrhages

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17
Q

Give 2 examples of AV malformations that may lead to SAH

A

Dural AV fistula
Venous sinus thrombosis
Vasculopathy

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18
Q

What are the main RFs for an intracranial aneurysm?
What are the 3 most common sites for an intracranial aneurysm?

A

Polycystic Kidney disease, Atherosclerosis (HTN, dyslipidemia, smoking) but majority idiopathic
Ant. communicating artery (40%), MCA bifurcation (35%), Vertebral artery

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19
Q

What are the RFs for SAH?

A

Family history of SAH, aneurysms, atherosclerosis
AD polycystic kidney disease
RFs for atherosclerosis: smoking, HTN, dyslipidemia
Inherited Connective Tissue disease: e.g. Marphans

20
Q

What are the complications of SAH? (4)

A

Focal neurological deficit/cranial nerves
Rebleeding risk (80% mortality)
!!Communicating hydrocephalus!!
Vasospasm

21
Q

What is the difference between a communicating and a non-communicating hydrocephalus?

A

Non-communicating = obstructive => obstruction to flow
Communicating means reduced CSF resorption but flow still occurs

22
Q

What is a vasospasm?

A

Vasospasm is the sudden vasoconstriction of vessels leading to ischemia

23
Q

The risk of rebleeding is very high when it comes to SAH, specifically aneurysms and is associated with 80% mortality.
If untreated, What period is rebleeding most common? When is the peak?

A

rebleeding is most common within 4 weeks (40%) with the peak at 1 week

24
Q

Non-contrast CT Brain conducted on a patient with suspected SAH confirmed the diagnosis. What is the next step in your investigation? Explain its purpose

A

Non-contrast CT brain followed by CT angiogram to:
1) Determine location of aneurysm/cause of SAH
2) Characterize aneurysm in terms of risk of rebleeding and appropriate treatment option

25
Q

a 35 year old male with no previous history presents by ambulance to the ED with symptoms of SAH (below). Assume Aneurysm to be the cause but proceed as a real case (still do investigations within)
Abrupt severe headaches, describes it as worst headache of their life
nausea and vomiting
collapsed, LOC for 10 minutes witnessed by wife
Confused and drowsy
Neck stiffness and photophobia
No focal neurological deficits
Give your full management plan

A

This is a clear case of SAH

1) Basic Management:
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)

Begin with Non-contrast CT Brain or lumbar puncture to confirm diagnosis and exclude hemorrhage before proceeding to CT angiogram to determine location, risk of rebleeding and appropriate tx

2) Definitive Treatment: Interventional radiology
Aneurysm Coiling if uncomplicated aneurysm with CT angio/MRI followup in 6 months for regrowth
Neurosurgical Clipping if complicated (due to position, size, or morphology)

26
Q

What is aneurysm coiling? (give procedure)
What is the standard follow-up for this procedure? Why is there a followup?
What are the complications associated with this procedure?

A

Patient under GA, sheath placed in femoral artery and then uses a guide catheter to the common carotid artery where microcatheter and microwire access the aneurysm and place detachable coils within aneurysm
Follow up in 6 months with CT angio/MRI for regrowth
Complications: Perforation causing rebleed (high mortality), stroke, and vasospasm

27
Q

When is neurosurgical clipping indicated for SAH?
What is neurosurgical clipping? (give procedure)
This patient has a history of DVT and atherosclerosis. If they were to have a stroke, within what period of time are they contraindicated for thrombolysis? What would the alternate treatment option be?

A

Confirmed aneurysm on CT angiogram that is complicated (based on size, position, and morphology)
Procedure: Patient under GA, craniotomy performed, -> exposure of aneurysm -> closure of base with metal clip
Thrombolysis contraindicated for 2 months after a craniotomy (also applies for stroke or TIA during this period ironically). The alternate treatment option would be a thrombectomy

28
Q

What is shown in image A?
What is shown in image B?

A

Image A: Shows tracks along fissures and sulci (bright) => SAH
Image B: subarachnoid haemorrhage with extensive intraventricular blood and associated communicating hydrocephalus (Complication)

Extra: Image C shows VP shunt which is the treatment for hydrocephalus

29
Q

What is shown in this image?
What is the most likely diagnosis?
What is the most common cause?
What is it associated with?

A

Crescent/convex shaped bleeding + !!Venous bridging!! => Subdural hematoma
Most common cause is Trauma
A/w elderly, children and alcohol abuse

30
Q

What is shown in this image?
What is the most likely diagnosis?
What are the most likely causes?
What is an expected finding in the history of presenting complaint?

A

Lentiform/biconvex pattern of bleeding => Epidural hematoma
Most common causes are trauma (skull fracture) or post-op

Hx of PC: Lucid interval

31
Q

What is shown in this image?
Give the causes? Separate traumatic from pathological
If this is left untreated what may it progress to?

A

Intraparenchymal hemorrhage + midline shift
Same as SAH except for the aneurysm => AV malformation, HTN, tumor + !Subdural Hematoma!
!!!trauma (contusions, diffuse axonal injuries)!!!

Intraventricular hemorrhage

32
Q

What is shown in this image?

A

Intraventricular hemorrhage

33
Q

A person with a history of alcohol abuse and seizures presents with nausea and vomiting. You conduct a non-contrast CT brain. What findings are you likely to obtain?

A

Crescent/convex shaped bleeding + !!Venous bridging!! => Subdural hematoma
a/w alcohol abuse

34
Q

A 59 year old man presents to the OPD with a gradually worsening headache. He said he suffered from a blow to the head a week ago but wasn’t in much pain after that. What is the most likely type of hemorrhage the patient suffered from?
The patient describes the worsening headache, what other findings would you be looking for?
What age group is associated with this presentation? why?

A

Chronic Subdural. It is the only one with an insidious onset

1) Evidence of raised ICP (50% present with this)
2)Looking for progressive neurological deficits such as weakness, hypotonia, dysmetria, being increasingly somnolent and unresponsive etc…

Common in (children and) elderly as the brain shrinks as they get older => tearing of bridging veins over time

35
Q

A 48 year old patient is 1 week post-op and presents with severe headaches appearing apparently out of no where. What is the most likely hematoma to be found on non-contrast CT brain?

A

Epidural hematoma
Evidence from being post-op as well as lucid interval

36
Q

Which hematoma is most associated with altered mental status?

A

Epidural hematoma

37
Q

What type of blood is hemorrhaging in each of the types of brain hemorrhages? (5)

A

Subdural: venous
SAH and Epidural: Arterial
Intraparenchymal and intraventricular: Can be either

38
Q

T or F: Interventional radiology can offer treatment for patients with traumatic SAH

A

False, non-traumatic AKA aneurysm

39
Q

T or F: Interventional radiology can offer treatment for patients with non-traumatic SAH

A

True

40
Q

Which type of hematoma is most likely in a fist fight? Why?
What type of fracture is associated with the first fight?

A

Epidural. As the pterion (Temporal bone fracture) is the weakest point and is a common fracture with a blow to the head. It has the middle meningeal artery running under it causing epidural hematoma if ruptured.

41
Q

Within what time frame should intracranial hematomas be treated?

A

within 2-4 hours ideally

42
Q

What is the treatment for an epidural hematoma?

A

Early emergency craniotomy ideally within 2-4 hours

43
Q

What findings are associated with subdural hematomas?
What other hemorrhage is associated with subdural hemorrhages?
What is meant by acute and chronic subdural hematomas? How do their treatment options differ?
What is the typical presentation of chronic subdural hematoma?

A

Findings: Midline shift, Venous bridging, Crescent/convex shaped bleeding covering entire cerebral surface

A/w intraparenchymal/intracerebral hemorrhage

Acute refers to the trauma causing the damage to bridging veins whereas in chronic (for e.g. elderly, it is due to shrinking brain with age leading to tearing over time)
Acute Tx: Emergency craniotomy within 2-4 hours
Chronic Tx: Burrhole drainage with warm saline washout

Normal presentation: Children or elderly over 60 presenting with
1) Raised ICP (50% present this way)
2) Progressive neurological deficits (worsening headache somnolence, weakness, cranial nerve…)

44
Q

A 49 year old patient suffered a major RTA hitting their head severely on the steering wheel but fortunately no fractures. What is the most common brain bleed likely to be found?
What imaging would you order and what are the expected findings?
What finding on the imaging would indicate a need for treatment and state the treatment)

A

An RTA is indicative of a diffuse axonal injury (primary brain injury) which is most associated with Intraparenchymal/intracerebral hemorrhages
Non-contrast CT: Midline shift
If midline shift >5mm => Evacuation of hematoma

45
Q

What are the guiding indications for surgery in an intracranial bleed?

A

1) Signs of raised ICP
2) midline shift on CT >5mm

Surgical Emergencies (13 decks)

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