Spontaneous Intercranial Haemorrhage Flashcards
what are the types of spontaneous intracranial haemorrhage
subarachonid
intracerebral
intraventricular
what usually causes a spontaneous subarachnoid haemorrhage (SAH)
berry aneurysm rupture
sometimes AVM/ no underlying cause
what is the mortality like in spontaneous SAH
46% at 30 days
fatal if diagnosis missed
where do berry aneurysm arise from
junction of circle of willis
what is the presentation of a spontaneous SAH
sudden onset severe headache (like being hit by bat) (will persist due to chemical meningitis caused by blood) collapse vomiting neck pain photophobia may have decreased consciouness
what are the differentials a sudden onset headache
SAH
migraine
benign coital cephalgia (severe sudden onset HA after exertion)
what are signs in a spontaneous SAH
neck stiffness
photophobia
-/+ decreased conscious level
+/- focal neurolofical deficit (dysphasia, hemiparesis, III nerve palsy)- depends which part of brain gets ischaemic/ damaged by blood
on fundoscopy- retinal or vitreous haemorrhage
what diagnostic test for SAH
CT
may be negative if >3 days post
negative in 15% of patients who have bled
what colour is CSF on CT
black- low density
what colour is blood on CT
high density- bright as lots of ions
when can you so a LP in suspected SAH
if CT is negative
when no focal neuro deficit and no papilloedema
what will CSF look like in an LP of SAH
bloodstained or xanthochromic (yellow staining due to breakdown of blood products)
differentiate from a traumatic tap
what is the gold standard for a SAH
cerebral angiography
what are the complications of SAH
re bleeding - often fatal delayed ischaemic deficit hydrocephalus hyponatraemia seizures
how do you prevent re bleeding in a spontaneous SAH
endovascular techniques to exclude aneurysm from circulation (e.g. platinum coil)
surgical clipping
how do atheromas cause aneurysm
inflammatory damage from the atheroma, damage vessels
what are the features of a delayed ischaemia in SAH
happens 3-12 days after bleed
-altered conscious level of focal deficit
caused by the inflammatory response to the blood irritates the vessels and causes them to go into vasospasm
what treatment for a delayed ischaemia in an SAH
nimodipine- calcium channel blocker
triple H fluid therapy- achieve hypervolaemia, hypertension, hemodilution
what is the treatment for hydrocephalus in SAH
CSF drainage- LP, EVD, shunt
what can cause hyponatraemia in SAH
SIADH
cerebral salt wasting (abnormal secretion of hormones that cause salt excretion)
what is the treatment for hyponatraemia in SAH
often transient
DO NOT fluid restrict as will cause vasospasm in SAH
supplement sodium intake
fludrocortisone- encourages sodium retention
what does SAH do to seizure threshold
decreases it
can give anticonvulsant prophylaxis- controversial
what is the general treatment for a spontaneous SAH
CT +/- LP bedrest analgesia anti emetic IV fluids refer to neurosurgeons
what is the outcome for a spontaneous SAH usually
poor
high mortality
those that do ‘well’ 66% don’t return to previous occupation
what usually causes an spontaneous intracerebral haemorrhage
50% hypertension
30% aneurysm/ AVM
bleeding diatheses, tumours, drugs (warfarin, heparin)
what is an intracerebral haemorrhage (ICH)
bleeding into the brain parenchyma
what causes a hypertensive ICH
microaneurysms arising on small perforating arteries
creates a basal ganglia haematoma
what is the presentation of a spontaneous ICH
headache that is not as sudden onset of severe as SAH
focal neurological deficit
decreased conscious level in big bleeds (reduced cerebral perfusion)
what investigations into ICH
CT - urgent if decreased conscious level
angiography if suspicious of underlying vascular anomaly (dont need to do in classical hypertensive basal ganglia bleed)
what is the treatment for a spontaneous ICH
surgical evacuation of heamatoma +/- treatment of underlying abnormality (esp if decreased conscious level)
non surgical management (if normal conscious level)
what is the prognosis for spontaneous ICH
good- if small superficial clot and good neurological status
poor- if large basal ganglia or thalamic clot with major focal deficit or deep coma
what causes an spontaneous intraventricular haemorrhage
rupture of a subarachnoid or intracerebral bleed into a ventricle
(any combo of SAH, ICH and intraventrciular haemorrhage can occur)
what are AVMs in the brain like
arterio venous shunts
usually intraparenchymal
congenital
what are the complications of a brain AVM
seizures
haemorrhage- ICH, SAH, subdural
headache
steal syndrome s
what surrounds an AVM
draining veins
what is the treatment for AVMs
surgery - excision
endovasular embolisation
stereotactic radiotherapy (gamma rays slowly shrink it)
conservative
weight risks and benefits
