Week 5 - B -Intracranial haemorrhage - Subarachnoid, Intracerebral, intraventricular (Little on migraine, cluster & tension headache)

Question 1

What is a subarachnoid haemorrhage? What are the usual two main causative factors of subarachnoid haemorrhage?

Answer 1

Subarachnoid haemorrhage is the bleeding into the subarachnoid space It is usually due to berry aneurysm rupture, also known as a sacular aneurysm which accounts for around 80% of cases Less commonly is the arteriovenous malformation (AVM) as a case which accounts for 10-15% In some cases there is no underlying cause found for the bleed

Question 2

Where are berry aneurysm typically found?

Answer 2

The berry aneursyms are usually found at junctions in the circle of willis in the brain

Question 3

What makes up the circle of willis?

Answer 3

Circle of willis

• The anterior cerebral arteries x2
• Anterior communicating artery x1 joining them
• Middle cerebral arteries x2
• Internal carotid arteries x2
• Posterior communicating arteries x2
• Posterior cerebral arteries x2

Question 4

What are the common junctions for berry aneurysms?

Answer 4

• Where the anterior communicating meets anterior cerebral arteries
• Where the middle cerebral artery bifrucates
• Where the posterior communicating meets the internal carotid artery
• Where the posterior cerebral arteries meet

Question 5

How does subarachnoid haemorrhage present?

Answer 5

There is the sudden onset of severe headache - like somebody kicked you in the head Associated with nausea, vomiting, neck pain and photophobia

Question 6

If the SAH isnt treated, what can follow the initial symptoms of vomiting, nausea, headache, photphobia and neck stiffness?

Answer 6

Seziures and coma can often follow

Question 7

What is the differential diagnosis of subarachnoid haemorrhage?

Answer 7

Subarachnoid haemorrhage Migraine Benign coital cephalgia

Question 8

Describe the features of a migraine and of benign coital cephalgia

Answer 8

Migraine (usually affects woman) - headaches typically lasting 4-72 hours Associated with at least two of the following - unilateral, moderate-severe, pulsating and worse on movement Associated with at least one of - photophobia, phonophobia, nausea and/or vomiting Benign coital cephalgia - this is a headache that is rare and occurs during sex, begins as a dull headache that increases with sexual excitement, and becomes intense at orgasm.

Question 9

How does a migraine differ from a tension headache and a cluster headache?

Answer 9

Tension headahce

• Typically mild-moderate and is a bilateral, non pulsating headache - can last hours-days, not affected by movement Absence of nausea/vomiting, photophobia or phonophobia

Cluster headache

• Unilateral severe headache, that lasts typically 15 minutes to 3 hours, occurs from 1 to 8 times per day for a couple months Have cranial autonomic feature - ptosis, eye watering, miosis, nose stuffiness, nausea and vomiting - usually affects men

Question 10

What are signs on examination of subarachnoid haemorrhage?

Answer 10

Neck stiffness Photphobia Decreased consciousness level Also can have focal neurological deficit Fundoscopy - retinal or vitreous hemorrhage

Question 11

What are the two signs in patients with meningitis that a physician can elecit on examination? One of these signs is also visible in SAH - usually takes 6hours to develop?

Answer 11

This would be Brudzinski’s and Kernig’s sign

• Brudzinski’s - this is where on passive flexion of the neck, the patient knees flex
• Kernig’s - with the patient lying supine, when knees are passively flexed, they cannot be extended
• Kernig’s sign is visible after 6 hours in SAH

Question 12

Why are there features of meningism in subarachnoid haemorrhage?

Answer 12

• Signs of meningism (vomiting, photophobia, neck pain) because blood irritates meninges

Question 13

What is the diagnostic test for SAH? What percentage of patents is this negative?

Answer 13

CT is the diagnostic test Negative in 15% of patients who have bled however and may be negative if >3 days post ictus

Question 14

If the CT is negative and there is no contraindications, what is the next procedure carried out and when is it carried out?

Answer 14

If the CT scan is negative and there are no contraindications ie rising ICP, then a lumbar puncture can be carried out 12hours after headache onset

Question 15

When would a lumbar puncture be safe to carry out? How does lumbar puncture differentiate blood in CSF from a traumatic tap procedure due to a ruptured vein when using the needle? How long does guidelines recommend waiting and why?

Answer 15

Would be safe to carry out in an alert patient, with no focal neurological deficit and no papilloedema after a normal CT

The blood on lumbar puncture will be old blood characteristically known as xanthochromic (yellow) whereas a traumatic tap would show fresh red blood

Question 16

Where are the aneursyms seen here located?

Answer 16

The patient had a large anterior communicating artery aneursym - at where this artery meets the anterior cerebral artery and another aneurysm in the middle cerebral artery - at the bifurcation

Question 17

What are complications of subarachnoid haemorrhage? Which complication is the commonest cause of death in SAH? Which is the commonest cause of cause of morbidity in SAH?

Answer 17

Complications: * Re-bleeding - commonest cause of death in SAH * Cerebral ischaemia due to vasospasm may cause a permanent CNS deficit - commonest cause of morbidity * Hydrocephalus * Hyponatreamia * Seziures

Question 18

What is the risk of rebleeding in the first 14 days and within the first 6 months after a sub arachnoid haemorrhage?

Answer 18

Risk of re-bleeding is 20% in the first 14 days after the SAH Risk of re-bleeding is 50% in the first 6 months after the SAH

Question 19

When there is a proven subarachnoid hemorrhage, where should all cases be referred to immediately?

Answer 19

All cases of proven subarachnoid haemorrhage should be referred to neurosurgery immediately

Question 20

What is given as treatment for the SAH to prevent the risk of rebleeding? What should be assessed before intervening with this treatment?

Answer 20

Endovascular coiling is the preferred method to prevent re-bleeding over surgical clipping of aneurysms Before carrying out this procedure - catheter or CT angiography should be carried out to assess for single or multiple aneurysms

Question 21

Delayed ischaemia - aka delayed ischaemia neurological deficit - can occur after a SAH and is very common How many days after the event does this present and what are the signs?

Answer 21

Presents 3-12 days after the SAH as altered consciousness level of focal deficit

Question 22

What is the triple H therapy that is advised for patients with subarachnoid haemorrhage? What is given to treat the vasospams and how does this drug work?

Answer 22

Hypertension, hypovalaemia, haemodilution Want to maintain a systolic blood pressure >/=160mmHg and keep well hydrated as well as correcting any following sodium levels To treat the vasopsams give nimodipine - a calcium channel blocker This is the treatment to prevent delayed ischaemic neurological defecit

Question 23

What is the overall treatment of subarachnoid haemorrhage then?

Answer 23

Preventing re-bleeding Cather or CT angiography to assess single or multiple aneurysm Endovascular coiling over surgical clipping Preventing delayed ischaemic neurological deficit Nimodipine - reduces vasospams (calcium channel blocker)

Triple H therapy - hypertension (maintain systolic at>/=160 mmHG), haemodiluton, correct hyponatraemia

Also give seizure prophylaxis - phenytoin i think

Potentially consider a stool softener as well because constipation can increase

Question 24

Nimodipine is a dihydropyridine calcium channel blocker. Name another dihydropyridine calcium channel blocker What type of calcium channels do both of these act upon?

Answer 24

Another dihydropyridine calcium channel blocker is amlodopine These both work on L-type calcium channels

Question 25

Hydrocephalus can occur due to SAH. How might this occur? What is normally the treatment?

Answer 25

Hydroecephalus can occur due to blockage of the arachnoid granulations It is often transient but if treatment is required then VP shunt - ventriculoperitoneal shunt or lumbar drain

Question 26

Hyponatraemia can occur as a complication of SAH usually due to hypothalamic ischaemia meaning inappropriate ADH is excreted from the pituitary How does this cause hyponatreamia? Fluid restriction is very important here - T or F What is the management?

Answer 26

The increased ADH secretion increases absorption of water meaning the blood becomes hypotonic, to restore tonicity sodium is secreted in the urine meaning patient becomes hyponatraemic Do not fluid restrict as blood will become thick and sticky potentially worsening the DIND Management - sodium supplementing and if severe fludricortisone to promote sodium reabsorption

Question 27

Another type of intracranial haemorrhage is intracerebral haemorrhage What happens here and what are the causes?

Answer 27

This is where there is bleeding into the brain parenchyma 50% of causes are due to hypertension 30% of causes are due to arteriovenous malformation This is bleeding into the brain itself Tends not to be as sudden and as severe as SAH Because intracerebral haemohragge bleeds into the brain however tends to have neurological defecit

Question 28

Coronal slice through the brain Big black thing is a blood clot in the brain Usuaully the bleed arises from the perforating arteries here What are the perforating arteries where the bleeds occur from known as?

Answer 28

It is the lenticulostriate arteries that is the perforating arteries that usually rupture in intracerebral haemorrhage - these supply the internal capsule

Question 29

What are the minute aneurysms which develop as a result of chronic hypertension and appear most commonly in the basal ganglia and other areas such as the thalamus, pons and cerebellum, where there are small penetrating vessels? What are intracerebral haemorrhages a type of?

Answer 29

These are the charcot bouchard aneurysms Intracerebral hemorrhages are a type of stroke

Question 30

Which artery do the lenticylostriate arteries come of to supply the internal capsule and basal ganglia of the brain?

Answer 30

The lenticulostriate arteries come from the middle cerebral artery

Question 31

Label the numbered arteries

Answer 31

1. Lenticulostriate Arteries 2. Middle Cerebral Artery 3. Internal Carotid Artery

Question 32

What are the different parts of the basal ganglia?

Answer 32

Caudate nucleus Putamen Globus pallidus Subthalamic nucleus Substantia nigra Caudate nucleus + putamen - striatum Caudate nucleus + putamen + globus pallidus = corpus striatum Putamen + globus pallidus = lentiform nculeus

Question 33

What is the presentation of an intracerebral haemorrhage?

Answer 33

Headache Focal neurological deficit - usually hemiparesis or hemiplegia - Neurologists use the term paresis to describe weakness, and plegia to describe paralysis in which all voluntary movement is lost. Decreased consciousness level

Question 34

What are the intitial urgent investigations for someone you believe may be having a stroke? (whether it haemorrhagic (intracerbral bleed) or ischaemic stroke) What is carried out if suspecting an underlying vascular anomaly? (AVM)

Answer 34

Would do an urgent CT scan of the brain If suspecting an underlying vascular anomaly then carry out angiography Intracerebral bleed shown in the picture

Question 35

What is the treatment of inntracerebral hemorrhages?

Answer 35

If a small haemorrhage then non-surgical management

If the haematoma is large in the brain (ie >3cm) - then surgical evacuation of haematoma and treatment of underlying abnormality Depending on the location of the clot, possibly either a craniotomy orstereotactic aspiration of haematoma may be performed.

Question 36

What is the white circle in the centre of the scan? What does it help one identify?

Answer 36

The white circle is the pineal gland Helps to identify any midline shift cause by space occupying lesions - ie haematoma due to intrcerebral haemorrhage

Question 37

Occurs with rupture of a subarachnoid or intracerebral bleed into a ventricle What is this?

Answer 37

This is an intraventricular haemorrhage Any combination of subarachnoid, intracerebral and intraventricular haemorrhage can occur

Question 38

Arteriovenous malformations are much rarer than aneurysms but do crop up from time to time Where are the general symptoms of AVMs usually?

Answer 38

The general symptoms of AVMs are usually headaches and seizures when bleeding occurs

Question 39

What is the treatment of AVMs? What is important when treating them?

Answer 39

It is important to remove the AVM completley without damaging the healthy blood supply Can be done by surgery -ie endovscular-embolisation or non surgical - sterotactic radiation - a high dose targeted radiotherapy dose aimed at the AVM to obliterate it Pic Shows a Treated AVM