Spontaneous Intercranial Haemorrhage

Question 1

what are the types of spontaneous intracranial haemorrhage

Answer 1

subarachonid
intracerebral
intraventricular

Question 2

what usually causes a spontaneous subarachnoid haemorrhage (SAH)

Answer 2

berry aneurysm rupture

sometimes AVM/ no underlying cause

Question 3

what is the mortality like in spontaneous SAH

Answer 3

46% at 30 days

fatal if diagnosis missed

Question 4

where do berry aneurysm arise from

Answer 4

junction of circle of willis

Question 5

what is the presentation of a spontaneous SAH

Answer 5

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

Question 6

what are the differentials a sudden onset headache

Answer 6

SAH
migraine
benign coital cephalgia (severe sudden onset HA after exertion)

Question 7

what are signs in a spontaneous SAH

Answer 7

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

Question 8

what diagnostic test for SAH

Answer 8

CT
may be negative if >3 days post
negative in 15% of patients who have bled

Question 9

what colour is CSF on CT

Answer 9

black- low density

Question 10

what colour is blood on CT

Answer 10

high density- bright as lots of ions

Question 11

when can you so a LP in suspected SAH

Answer 11

if CT is negative

when no focal neuro deficit and no papilloedema

Question 12

what will CSF look like in an LP of SAH

Answer 12

bloodstained or xanthochromic (yellow staining due to breakdown of blood products)

differentiate from a traumatic tap

Question 13

what is the gold standard for a SAH

Answer 13

cerebral angiography

Question 14

what are the complications of SAH

Answer 14

re bleeding - often fatal
delayed ischaemic deficit 
hydrocephalus
hyponatraemia 
seizures

Question 15

how do you prevent re bleeding in a spontaneous SAH

Answer 15

endovascular techniques to exclude aneurysm from circulation (e.g. platinum coil)
surgical clipping

Question 16

how do atheromas cause aneurysm

Answer 16

inflammatory damage from the atheroma, damage vessels

Question 17

what are the features of a delayed ischaemia in SAH

Answer 17

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

Question 18

what treatment for a delayed ischaemia in an SAH

Answer 18

nimodipine- calcium channel blocker

triple H fluid therapy- achieve hypervolaemia, hypertension, hemodilution

Question 19

what is the treatment for hydrocephalus in SAH

Answer 19

CSF drainage- LP, EVD, shunt

Question 20

what can cause hyponatraemia in SAH

Answer 20

SIADH

cerebral salt wasting (abnormal secretion of hormones that cause salt excretion)

Question 21

what is the treatment for hyponatraemia in SAH

Answer 21

often transient
DO NOT fluid restrict as will cause vasospasm in SAH
supplement sodium intake
fludrocortisone- encourages sodium retention

Question 22

what does SAH do to seizure threshold

Answer 22

decreases it

can give anticonvulsant prophylaxis- controversial

Question 23

what is the general treatment for a spontaneous SAH

Answer 23

CT +/- LP
bedrest 
analgesia
anti emetic
IV fluids 
refer to neurosurgeons

Question 24

what is the outcome for a spontaneous SAH usually

Answer 24

poor
high mortality
those that do ‘well’ 66% don’t return to previous occupation

Question 25

what usually causes an spontaneous intracerebral haemorrhage

Answer 25

50% hypertension
30% aneurysm/ AVM

bleeding diatheses, tumours, drugs (warfarin, heparin)

Question 26

what is an intracerebral haemorrhage (ICH)

Answer 26

bleeding into the brain parenchyma

Question 27

what causes a hypertensive ICH

Answer 27

microaneurysms arising on small perforating arteries

creates a basal ganglia haematoma

Question 28

what is the presentation of a spontaneous ICH

Answer 28

headache that is not as sudden onset of severe as SAH
focal neurological deficit
decreased conscious level in big bleeds (reduced cerebral perfusion)

Question 29

what investigations into ICH

Answer 29

CT - urgent if decreased conscious level

angiography if suspicious of underlying vascular anomaly (dont need to do in classical hypertensive basal ganglia bleed)

Question 30

what is the treatment for a spontaneous ICH

Answer 30

surgical evacuation of heamatoma +/- treatment of underlying abnormality (esp if decreased conscious level)

non surgical management (if normal conscious level)

Question 31

what is the prognosis for spontaneous ICH

Answer 31

good- if small superficial clot and good neurological status

poor- if large basal ganglia or thalamic clot with major focal deficit or deep coma

Question 32

what causes an spontaneous intraventricular haemorrhage

Answer 32

rupture of a subarachnoid or intracerebral bleed into a ventricle
(any combo of SAH, ICH and intraventrciular haemorrhage can occur)

Question 33

what are AVMs in the brain like

Answer 33

arterio venous shunts
usually intraparenchymal
congenital

Question 34

what are the complications of a brain AVM

Answer 34

seizures
haemorrhage- ICH, SAH, subdural
headache
steal syndrome s

Question 35

what surrounds an AVM

Answer 35

draining veins

Question 36

what is the treatment for AVMs

Answer 36

surgery - excision
endovasular embolisation
stereotactic radiotherapy (gamma rays slowly shrink it)
conservative

weight risks and benefits