Week 5- intracranial haemorrhage and spinal cord compression Flashcards
What sort of aneurysm usually underlies subarachnoid haemorrhages?
Berry aneurysm
Presentation of subarachnoid haemorrhage?
Sudden onset headache- one second its normal and the next you have an excruciating headache. Collapse Vomiting Neck pain Photophobia
What are the differential diagnosis of sudden onset headache?
Subarachnoid headache
Migraine
Benign coital cephalgia
Signs in subarachnoid haemorrhage?
Focal neurological deficit (dysphagia, hemiparesis, third nerve palsy)
Fundoscopy- retinal or vitreous haemorrhage
Decreased conscious level
Photophobia
Neck stiffness
What will a CT scan of the brain in SAH show?
May be negative if >3 days.
CSF is constantly being generated and absorbed so if the patient comes in straight away- there will be obvious blood on the CT. However if you wait a few days you may not see blood.
What colour is the CSF normally on CT and what happens to it in subarachnoid haemorrhage?
Normally the CSF is blackish on CT because its low density. However blood shows up white.
When is lumbar puncture safe in subarachnoid haemorrhage?
Safe in alert patient with no focal neurological deficit and no papilloedema. Or after a normal CT scan.
What will a lumbar puncture of a subarachnoid haemorrhage show?
Blood stained or xanthochromic CSF.
How would you differentiate from a traumatic tap and a subarachnoid haemorrhage?
Take three small CSF samples labelled one to three. If the blood is less in the third one than the first one then its a traumatic tap. The CSF slowly washes the blood away.
If the blood is consistent- then its a subarachnoid.
What other investigations once you’ve confirmed a subarachnoid haemorrhage would you do?
A cerebral angiography. Gold standard treatment- however small chance an aneurysm will be missed due to vasospasm.
Name some complications of subarachnoid haemorrhage
Re-bleeding Delayed ischaemic deficit Hydrocephalus Hyponatraemia Seizures
What techniques stop re-bleeding?
Endovascular techniques
Surgical clipping is rarely done.
What is delayed ischaemic deficit?
Sometimes known as vasospasm.
All it means is the brain becomes ischaemic in areas.
When does delayed ischaemic deficit usually present?
3-12 days.
What is the treatment for delayed ischaemic deficit?
Give nimodipine
Triple H therapy- hypervolaemia, hypertension and haemodilution.
What does delayed ischaemic deficit look like on CT?
The dead brain tissue looks black.
What is the treatment for hydrocephalus?
CSF drainage- could be lumbar puncture or shunt.
What is the management of hyponatraemia in subarachnoid haemorrhage patients?
Give sodium supplementation- do not fluid restrict.
What is an intracerebral haemorrhage?
Bleeding into the brain parenchyma.
What causes intracerebral haemorrhage?
50% are due to hypertension
30% due to aneurysms or AVM.
Describe the process of hypertension causing intracerebral haemorrhage? What does this result in?
Tiny aneurysms (Charcot Bouchard micro aneurysms) on blood vessels occur due to degenerative mechanisms from hypertension. This results in basal ganglia haematoma.