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Gwen - Neurology > Subarrachnoid haemorrhage > Flashcards

Subarrachnoid haemorrhage Flashcards

1
Q

What is xanthochromia?

A

Yellowish appearance of cerebrospinal fluid that occurs several hours after bleeding into the subarachnoid space caused by certain medical conditions, most commonly subarachnoid hemorrhage. Blood breakdown products.

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2
Q

What are vascular causes of a thunderclap headache?

A
  • SAH
  • Venous sinus thrombosis
  • Arterial dissection
  • Stroke
  • ICH
  • Vasculitis
  • Reversible cerebrovascular vasoconstriciton syndrome
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3
Q

What are non-vascular causes of thunderclap headache?

A
  • Spontaneous intracranial hypotension
  • Hypertensive encephalopathy
  • Meningitis
  • SOL
  • Pituitary apoplexy
  • Sinusitis
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4
Q

What is the definition of thunderclap headache?

A

It is defined as a severe headache/worst ever that takes seconds to minutes to reach maximum intensity (1-5 minutes)

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5
Q

What primary headache disorders would you consider if someone presented with thunderclap headache?

A
  • Primary cough
  • Coital
  • Exertional headache
  • Primary thunderclap headache
  • Migraine
  • Cluster headaches
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6
Q

What investigations would you do in someone with thunderclap headache?

A
  • Bloods - U+E, LFTs, FBC, Coag, CRP, BC if pyrexial
  • ECG
  • Urgent CT angio brain - DSA
  • Consider LP after 12 hours - if CT negative but strong clinical suspicion
  • Consider MRI - AVM malformation better viewed
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7
Q

What would you be looking for on LP in someone presenting with thunderclap headache?

A
  • Xanthochromia
  • Opening Pressure and constituents (raised pressure)

Wcc in meningitis

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8
Q

What is a subarachnoid haemorrhage?

A

Spontaneous arterial bleeding into the subarachnoid space, and is usually clearly recognizable clinically from its dramatic onset

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9
Q

What age range does subarachnoid haemorrhage?

A

35-65 (rare below 20)

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10
Q

What are causes of a subarachnoid haemorrhage?

A
  • Saccular (berry) aneurysm (80%)
  • AVM (15%)
  • Other rare causes (5%) - bleeding disorders, cavernous haemoangiomas, traumatic SAH, neoplasm, cortical thrombosis, encephalitis
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11
Q

What are common sites for berry aneurysms to occur?

A

Junctions of:

  • PCA and internal carotid
  • ACA and anterior cerebral artery
  • Bifurcation of MCA
  • Others - basilar, posterior inferior cerebellar, Intracavernous internal carotid
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12
Q

How do berry aneurysms cause symptoms?

A

Either by rupture or compression on surrounding structures

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13
Q

What are arteriovenous malformations?

A

Vascular developmental malformations, often with a fistula between arterial and venous systems causing high flow through the AVM and high pressure arterialization of draining veins

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14
Q

What is the risk (%) of first haemorrhage in someone with an AVM?

A

2-3% per year

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15
Q

What is the risk of rebleed in someone with AVM?

A

10% per year

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16
Q

What is the following?

A

Subarachnoid haemorrhage

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17
Q

What are features of subarachnoid haemorrhage on CT?

A

Hyperattenuating material is seen filling the subarachnoid space. Most commonly this is apparent around the circle of Willis, on account of the majority of berry aneurysms occurring in this region (~65%), or in the Sylvian fissure (~30%)

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18
Q

What are symptoms of a subarachnoid haemorrhage?

A
  • Sudden onset excruciating headache (thunderclap) - typically occipital
  • Other features of Meningism - Neck stiffness, photophobia, nausea/vomiting
  • Collapse and loss of consciousness (50%)
  • Seizures
  • Drowsiness - may last for days
  • Coma
  • Focal neurology may suggest site eg pupil changes suggesting CN 3 palsy with posterior communicating artery aneurysm (but could also be increased ICP!),
    6the nerve palsy could be flase localising due to hydrocephalus
19
Q

What can preceed a thunderclap headache caused by SAH?

A

Sentinal headache - indicative of small bleed before big from offending aneurysm

20
Q

What are signs of SAH?

A
  • Neck stiffness
  • Kernig’s sign - typically at least 6 hrs after
  • CNIII nerve palsy
  • Retinal, subhyaloid and vitrous haemorrhage - tracking below retinal hyaloid membrane
  • Papilloedema
  • Focal neurology indicating site
21
Q

A berry aneurysm in which location can cause a CNIII palsy?

A

Posterior communicating artery (PCOM) - sits next to CNIII

22
Q

If someone presented with symptoms of a sudden headache and features of meningism, what two main diagnoses would you want to rule out?

A
  • Subarachnoid haemorrhage
  • Meningitis
23
Q

Why does subarachnoid haemorrhage cause meningism?

A

Blood irritates the meninges, leading to inflammation

24
Q

Investigations subarachnoid haemorrhage

A

CT scan (detects >90% within first 48 hours)

Lumbar puncutre if CT neg

Cerebral angiography

Blood tests: Us and Es, haematology (Hb, WBC and clotting)

25
When is LP most sensitive for xanthochromia?
12 hours post haemorrhage
26
What are risk factors for SAH?
* **Previous SAH** * **Smoking** * **Alcohol** * **HTN** * **Bleeding Disorders** * **Family History** * **Polycystic kidneys** * **Coarctation of Aorta** * **Ehlers Danlos syndrome**
27
What would your differential diangosis be for sudden onset headache?
* **SAH** * **Meningitis** * **Migraine** * **Intracerebral bleed** * **Cortical vein thrombosis** * **Carotid/vetebral artery dissection** * **Benign thunderclap headache**
28
Why would you perform U+E's in someone with thunderclap headache?
Look for hyponatraemia + hypovolaemia from SAIDH or cerebral salt wasting -\> worsens vasopasm
29
Why might you do Coag screen and LFTs in someone with thuinderclap headache?
Look for signs of bleeding disorders which could cause SAH
30
How would you manage a SAH?
Refer to neurosurgery immediately * **ABCDE** * **Continuous neuro exam** * **Fluids** - keep well hydrated * **If seizures** - anticonvulsants * **Analgesia** * **Nimodipine** - reduces vasospasm (calcium channel blocker) * **Surgery** **Triple H therapy = hypertension, hypervolaemia and hyperdilution** (antihypertensives should be avoided because they increase ischaemic complications)
31
What surgical interventions are available for SAH repair?
* **Endovascular coiling** (prerable to clipping) * **Surgical clipping**
32
What is the more preferable surgical intervention for SAH?
**Endovascular coiling**
33
What are complications of SAH?
* **Rebleeding** - commonest cause of death * **Cerebral ischaemia due to vasospasm** - may cause permanent CNS defect * **Obstructive hydrocephalus** - due to blockage * **Hyponatraemia** - common but can be managed with fluid restriction
34
What can occur after the initial haemorrhage that occurs in SAH?
Vasospasm causing ischaemia and secondary brain damage
35
What proportion of those with SAH present with signs of TIA/Stroke?
25% - due to secondary vasospasm
36
When is risk of cerebral oedema and vasospasm greatest following a SAH?
Between 72 hrs and 10 days
37
What is the overal mortality rate of SAH?
**35-50%** - About 30% die within a few days, and another 10-15% within a few weeks. 1/6 will die before reaching hospital, 10% mortality rate in hospital.
38
When does someone who has had a SAH have the best prognosis?
**When no lesion is detected** - worst prognosis for aneurysms
39
Why might you do an ECG in someone with SAH?
50% of patients with SAH have an abnormal ECG on admission * **Arrhythmias** * **Prolonged QTc** * **ST segment/T wave abnormalities.**
40
What is the most accurate method for visualising aneurysms?
Digital subtraction angiography
41
When should an LP be performed in someone with SAH?
**If CT is unrevieling** - wait 12 hours for RBCs to start lysing
42
Where does the bleed happen in a SAH?
Between pia and arachnoid matter
43
What is associated wtih berry aneurysms
Polycystic kidneys Co-arctation of aorta Ehlers-danlos syndrome
44
How can AV malformations present?
INTRACRANIAL HAEMORRHAGE seizures FN defecit Headache Impaired higher cortical function Bruit

Gwen - Neurology (38 decks)

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