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YEAR 4 NEURO > Subarachnoid haemorrhage > Flashcards

Subarachnoid haemorrhage Flashcards

1
Q

Define a Subarachnoid Haemorrhage

A

presence of blood within the subarachnoid space, i.e. deep to the subarachnoid layer of the meninges

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2
Q

What two layers of the brain does blood sit between in a Subarachnoid Haemorrhage?

A

pia mater and arachnoid membrane

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3
Q

What are two ways we can classify a Subarachnoid Haemorrhage?

A

Spontaneous (70%)

Traumatic (30%)

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4
Q

What are some RF for a Subarachnoid Haemorrhage?

A

Smoking
HTN
excessive alcohol
Cocaine use
FHx

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5
Q

Which patients is a Subarachnoid Haemorrhage more common in?

A

Female pts
Black pts
Age 45-70yrs

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6
Q

Subarachnoid Haemorrhage is particularly associated with what conditions …?

A

Sickle cell anaemia

CT disorders - Marfans / Ehlos Danlos / APKD / coarctation of aorta (aneurysms)

Neurofibromatosis

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7
Q

List some causes of a spontaneous Subarachnoid Haemorrhage

A

Intracranial aneurysms

Arteriovenous malformation

Pituitary apoplexy

Arterial dissection

mycotic (infective aneurysms)

Perimesencephalic (idiopathic venous bleed)

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8
Q

What are the presenting features of a Subarachnoid Haemorrhage?

A

Headache: sudden onset, THUNDERCLAP

Nausea & vomiting

Meningism (neck stiffness / photophobia

back pain

Syncope / Coma

Seizures

Sudden death

ECG: ST elevation

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9
Q

Name and describe 2 physical tests which can demonstrate meningismus in Subarachnoid Haemorrhage?

A

Kernig sign:
Flex knee to 90 degrees >
Hip flexed to 90 degrees > Extend knee - elicit pain

Brudzinski sign:
Patient lies supine > flex neck > elicit knee flexion

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10
Q

What focal neurological signs might you see in a pt with Subarachnoid Haemorrhage?

A

Hemiparesis

Occulomotor nerve palsy

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11
Q

What clinical signs in the eye might you see in a pt with Subarachnoid Haemorrhage?

A

Retinal haemorrhage

Papilloedema - blurring of borders of optic disc

Isolated complete III-nerve palsy. *

  • secondary to compression by a posterior communicating artery (PCOM) aneurysm or / damage to the nerve due to blood in the subarachnoid space
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12
Q

What Investigations would you do for a pt with Subarachnoid Haemorrhage?

A

CT
1. W/in 6 hours: non contrast CT brain - show hyperdense blood ( if normal- no LP )
2. Outside 6 hours: Non contrast CT brain - if normal DO LP

LP / CSF
Performed 12 hours after onset of symptoms - xanthchromia

After SAH confirmed: looking for a cause

CT Angiography- for cause e.g. aneurysm / AVM

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13
Q

What are the benefits of doing a CT brain for a pt with Subarachnoid Haemorrhage?

A

Quick - 30 mins

Blood distribution can indicate site of aneurysm

Detect early hydrocephalus

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14
Q

What time frame is optimal to CT scan a pt with suspected Subarachnoid Haemorrhage?

A

w/in 6 hours = 100 % sensitivity

> 1 week = 50%

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15
Q

What will CT of brain show in a patient with Subarachnoid Haemorrhage?

A

Will see hyperattenuation due to fresh clots.

Acute blood is hyper-dense / bright on CT

Often see blood in basal cisterns, sulci, ventricular system.

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16
Q

Where should pts with Subarachnoid Haemorrhage be managed?

A

Specialist neurosurgical unit

17
Q

When would you order a LP for a patient with a suspected Subarachnoid Haemorrhage? ?

A

Confirm SAH if CT is negative (no blood seen in 7% pts)

at least 12 hours after onset of symptoms to allow for xanthochromia (up to 1 week)

18
Q

What findings are you looking for in a LP to confirm a Subarachnoid Haemorrhage? ?

A
  • Xanthochromia- RBC breakdown. (distinguishes SAH from ‘traumatic tap’)
  • normal or raised opening pressure
  • blood stained
  • lymphocytic reaction
  • elevated protein
19
Q

What are some predictive factors in Subarachnoid Haemorrhage?

A

consciousness
CT Scan

20
Q

How should you ensure a pt with an aneurysm is kept before treatment to prevent re-bleed of Subarachnoid Haemorrhage?

A

strict bed rest
controlled BP
No straining e.g. toilet

21
Q

What kind of MRI is useful for imaging Subarachnoid Haemorrhage?

A

Echo gradients show haemosiderin (black blob)

T2 FLAIR - increased T2 signal = blood (T2 shows water as white)

(Burton, Dr said “2 ladies drinking tea with a dash of milk” to remember this)

22
Q

When would Angiography be performed and why in the context of a Subarachnoid Haemorrhage?

A

To understand causative pathology :

e.g. CT intracranial angiogram for vascular lesion such as aneurysm or AVM

23
Q

What surgical intervention can be used for Subarachnoid Haemorrhage?

A

Coil
- interventional radiologist
- endovascular approach> catheter into arterial system> platinum coil into aneurysm, sealing it off from artery.

Clipping
- neurosurgeon
- craniotomy and clipping off the anueurysm

24
Q

Where should pts with Subarachnoid Haemorrhage be managed?

A

Specialist neurosurgical unit

Immediate referral once SAHis confirmed

25
Q

Why is vasospasm so dangerous in the context of Subarachnoid Haemorrhage?

A

cause mortality / neurological sequelae

Vasopasm is delayed often day 4-14 after SAH

Break down of blood products accumulating in subarachnoid causes irritation to the artery walls. Vasospasm narrows lumen of artery reducing blood flow and causing ischaemia

26
Q

What is used to prevent vasospasm for Subarachnoid Haemorrhage?

A

Nimodipine (calcium channel inhibitor working on brain vessels)

21 day course

27
Q

How is hydrocephalus treated in Subarachnoid Haemorrhage?

A

Short term:
External ventricular drain (CSF diverted to bag bedside bedside)

Long term:
Ventriculo-peritoneal shunt

28
Q

What are complications of an aneurysmal Subarachnoid Haemorrhage?

A

Re-bleeding (most common in first 12 hours > neuro symptoms? new CT please)

Vasospasm

Hyponatreamia (SIADH)

Seizures

Hydrocephalus

Death

29
Q

What are some predictive factors in Subarachnoid Haemorrhage?

A

conscious level on admission

age

amount of blood visible on CT head

30
Q

How should you ensure a pt with an aneurysm is kept before treatment to prevent re-bleed of Subarachnoid Haemorrhage?

A

strict bed rest

controlled BP

No straining e.g. toilet to prevent re-bleed

31
Q

What is involved in invasive angiography for Subarachnoid Haemorrhage?

A

DSA - Digital subtraction angiography (catheter angiogram)

Endovascular coiling is done at same time

32
Q

What is involved in non-invasive angiography for Subarachnoid Haemorrhage?

A

CTA

MRA

33
Q

What ECG changes could you see on a pt with Subarachnoid Haemorrhage?

A

ST elevation can be seen

34
Q

Pts who have reduced consciousness and a Subarachnoid Haemorrhage might need what?

A

Intubation and ventilation

35
Q

What support is needed from the multidisciplinary team for treatment of Subarachnoid Haemorrhage?

A

Nursing
Nutrition
physio
occupational therapy

YEAR 4 NEURO (37 decks)

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