Week 22 - Raised intercranial pressure, sub arach haemmorhage, subdural haematoma, vasovagal, tension headache

Question 1

how does one test for raised intracranial pressure

Answer 1

imaging - a CT of the head or MRI can reveal signs of raised ICP,

Question 2

what are the signs on imaging of raised ICP

Answer 2

enlarged ventricles
herniation
or mass effect from causes such as tumours, abscesses, haemoatomas

Question 3

what can you used to measure the pressure of the CSF

Answer 3

a lumbar puncture

Question 4

what do subarachnoid haemorrhages involve

Answer 4

bleeding into the subarachnoid space, where the CSF fluid is located, between the pia mater and the arachnoid membrane

Question 5

what is subarachnoid haemorrhage usually a result of

Answer 5

ruptured cerebral aneurysm

Question 6

subarachnoid haemorrhages are most common in who

Answer 6

aged 45-70
women
black ethnic origin

Question 7

what are the general risk factors for subarachnoid haemorrhage

Answer 7

hypertension
smoking
excessive alcohol intake

Question 8

what is subarachnoid haemorrhage particularly associated with

Answer 8

Family history
Cocaine use
Sickle cell anaemia
Connective tissue disorders (e.g., Marfan syndrome or Ehlers-Danlos syndrome)
Neurofibromatosis
Autosomal dominant polycystic kidney disease

Question 9

what is the typical history of a subarachnoid haemorrhage

Answer 9

sudden-onset occipital headache during strenuous activity, such as heavy lifting or sex

Question 10

what does the sudden and severe onset of activity lead to in subarachnoid haemorrhage

Answer 10

thunderclap headache description - may feel like being struck over the back of the head

Question 11

what are other important features of subarachnoid haemorrhage presentation

Answer 11

Neck stiffness
Photophobia
Vomiting
Neurological symptoms (e.g., visual changes, dysphasia, focal weakness, seizures and reduced consciousness)

Question 12

what is the first line investigation for subarachnoid haemorrhage

Answer 12

CT head

Question 13

what will be seen on a CT head with a subarachnoid

Answer 13

blood will cause hyper-attenuation in the subarachnoid space. however, a normal CT does not exclude a subarachnoid haemorrhage

Question 14

what is considered after a normal CT in the case of suspected Sub Arach

Answer 14

lumber puncture

NICE recommends waiting at least 12 hours after the symptoms start before performing a lumbar puncture, as it takes time for the bilirubin to accumulate in the CSF.

Question 15

what will a CSF sample show in the case of a sub arach

Answer 15

raised RBC - a decreasing red cell count on successive bottles may be due to a traumatic procedure

Xanthochromia - a yellow colour to the CSF caused by bilirubin

Question 16

what is used after confirming the diagnosis of a sub arach

Answer 16

CT angiogrpahy is used to locate the source of the bleeding

Question 17

what may be used to treat aneurysms

Answer 17

surgical intervention - this aims to repair the vessel and prevent re-bleeding.

this can be done by endovascular coiling, which involves inserting a catheter into the arterial system, placing platinum coils in the aneurysm and sealing it off from the artery

Question 18

what is used to prevent vasospasm - a common complication of sub arachs

Answer 18

nimodipine is a CCB used to prevent vasospasm

vasospasm resulting in brain ischaemia

Question 19

what are the treatment options for hydrocephalus in sub arachs

Answer 19

Lumbar puncture
External ventricular drain (a drain inserted into the brain ventricles to drain CSF)
Ventriculoperitoneal (VP) shunt (a catheter connecting the ventricles with the peritoneal cavity)

Question 20

what are the four types of intracranial haemorrhage

Answer 20

Extradural haemorrhage (bleeding between the skull and dura mater)

Subdural haemorrhage (bleeding between the dura mater and arachnoid mater)

Intracerebral haemorrhage (bleeding into brain tissue)

Subarachnoid haemorrhage (bleeding in the subarachnoid space)

Question 21

what are the risk factors for intracranial bleeds

Answer 21

Head injuries
Hypertension
Aneurysms
Ischaemic strokes (progressing to bleeding)
Brain tumours
Thrombocytopenia (low platelets)
Bleeding disorders (e.g., haemophilia)
Anticoagulants (e.g., DOACs or warfarin)

Question 22

what is the presentation of a intracranial bleed

Answer 22

Sudden-onset headache is a key feature. They can also present with:

Seizures
Vomiting
Reduced consciousness
Focal neurological symptoms (e.g., weakness)

Question 23

what is the minimum score on GCS

Answer 23

3/15

Question 24

where does an extradural haematoma occur

Answer 24

between the skull and dura mater

Question 25

what is an extradural haemorrhage usually caused by

Answer 25

a rupture of the MMA in the temporoparietal region

Question 26

what is an extradural haemorrhage associated with

Answer 26

a fracture of the temporal bone

Question 27

what is seen on a CT scan in the case of an extradural haemorrhage

Answer 27

they have a bi-convex shape and are limited by the cranial sutures (they do not cross the sutures, which are the points where the skull bones join together)

Question 28

where does a subdural haemorrhage occur between and what causes it

Answer 28

the dura mater and the arachnoid mater and is caused by a rupture of the bridging veins in the outermost meningeal layer

Question 29

what is seen on a CT of a subdural haemorrhage

Answer 29

they have a cresent shape and are not limited by the cranial sutures

Question 30

who do subdural haemorrhages occur mostly in

Answer 30

the elderly and alcoholic patients, who have more atrophy in their brains, making the vessels more prone to rupture

Question 31

what does intracerebral haemorrhage involve

Answer 31

bleeding in the brain tissue

Question 32

how does an intracerebral haemorrhage present

Answer 32

similarly to an ischaemic stroke with sudden onset focal neurological symptoms, such as limb or facial weakness, dysphasia or vision loss

Question 33

how do intracerebral haemorrhages occur

Answer 33

occur spontaneously or secondary to ischaemic stroke, tumours or aneurysm rupyure

Question 34

what does a subarachnoid haemorrhage involve

Answer 34

bleeding in the subarachnoid space where the CSF is located, between the pia mater and the arachnoid mater.

Question 35

what is a subarachnoid haemorrhage usually the result of

Answer 35

a ruptured cerebral aneurysm

Question 36

what is the typical history/presentation of a subarachnoid haemorrhage

Answer 36

sudden onset occipital headache during strenuous activity, such as heavy lifting or sex. the sudden and sever eonset leads to 'thunderclap headache'

Question 37

what is required immediately in the management of a potential brain bleed

Answer 37

CT head is required to establish a diagnosis

Question 38

what does initial management for an intracranial bleed involve

Answer 38

Admission to a specialist stroke centre Discuss with a specialist neurosurgical centre to consider surgical treatment Consider intubation, ventilation and intensive care if they have reduced consciousness Correct any clotting abnormality (e.g., platelet transfusions or vitamin K for warfarin) Correct severe hypertension but avoid hypotension

Question 39

what are the surgical options for treating an extradural or subdural haematoma

Answer 39

craniotomy (open surgery by removing a section of the skull) burr holes (small holes drilled into the skull to drain the blood)

Question 40

what percentage of all headaches do tension headaches account for

Answer 40

40% of all headaches

Question 41

how long do tension headaches last for and how often are they

Answer 41

they typically last for several hours, and often recur daily

Question 42

are symptoms of a tension headache uni or bi lateral

Answer 42

bilateral

Question 43

how do patients describe a tension headache

Answer 43

tight band sensation, pressure behind the eyes, can be across the whole top of the head, typically frontal with or without radiation to the occiput

Question 44

do tension headaches wake patients from their sleep

Answer 44

do not wake patients from their sleep - typically onset is after waking, often worse during the middle of the day

Question 45

are tension headaches sensitive to head movement and is there a feeling of needing to vomit

Answer 45

not sensitive to head movement no feeling of need to vomit generally no neurological signs

Question 46

does alcohol make a tension headache better or worse

Answer 46

better

Question 47

what are the causes of tension headaches

Answer 47

stress noise concentrated visual effort fumes/smells

Question 48

how is tension headache diagnosed

Answer 48

using the International Headache Society Criteria

Question 49

what does the International Headache Society criteria state

Answer 49

At least x10 episodes of similar headache Head duration 30 min – 7 days At least two of: Non-pulsating Mild or moderate intensity Bilateral Not aggravated by routine activity Must have both of: No nausea or vomiting No photophobia or phonophobia (or only one of these) Not attributable to another disorder

Question 50

in chronic tension headache, how often should one take analgesia

Answer 50

limit analgesia to 2-3 days per week

Question 51

what is a vasovagal episode caused by

Answer 51

caused by a problem with the autonomic nervous system regulating blood flow to the brain.

Question 52

what happens when the vagal nerve receives a strong stimulus, such as an emotional event, temperature or pain

Answer 52

it can stimulate the parasympathetic nervous system. Parasympathetic activation counteracts the sympathetic nervous system, which keeps the smooth muscles in blood vessels constricted. As the blood vessels delivering blood to the brain relax, the blood pressure in the cerebral circulation drops, leading to hypoperfusion of brain tissue. This causes the patient to lose consciousness and “faint”.

Question 53

how do patients usually feel before a vasovagal episode

Answer 53

Hot or clammy Sweaty Heavy Dizzy or lightheaded Vision going blurry or dark Headache

Question 54

how would an outsider describe a patient who had a vasovagal episode

Answer 54

Suddenly losing consciousness and falling to the ground Unconscious on the ground for a few seconds to a minute as blood returns to their brain There may be some twitching, shaking or convulsion activity, which can be confused with a seizure