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.
Presentation of intracerberal heamorrhage?
Headache- not as bad or sudden as subarachnoid haemorrhage
Focal neurological deficit- hemiplegia or hemiparesis is likely to be it.
Which investigations would you do into intracerebral haemorrhage?
CT scan- urgent if decreased conscious level.
Angiography if suspicion of underlying vascular abnormality.
Treatment of intracerebral haemorrhage?
Surgical evacuation of haematoma +/- treatment of underlying abnormality.
Non-surgical management
When does an intraventricular bleed occur?
Rupture of a subarachnoid or intracerberal haemorrhage into the ventricles.
What is an arteriovenous shunt?
An abnormal connection between an artery and vein. They are much rarer than aneurysms. Also known as AVMs
How would you treat an AVM?
Surgery
Endovascular embolisation
Stereotactic radiotherapy
Where does the upper motor neurone originate from and end in the corticospinal tract?
Originates in the motor cortex.
Ends in the grey matter of the anterior horn
Where do pathways decussate in the corticospinal tract ?
Medulla
What signs will show in an upper motor neurone lesion?
Increased tone
Brisk reflexes
No fasciculation
Muscle wasting not marked.
What signs will show in an lower motor neurone lesion?
Decreased tone
Muscle wasting
Fasciculation
Diminished reflexes.
What modalities does the spinothalmic pathway mediate?
Pain, temperature and crude touch.
Is the corticospinal tract contralateral or ipsilateral?
Ipsilateral
Is the spinothalamic pathway contralateral or ipsilateral?
Contralateral
When does the spinothalamic tract decussate?
At spinal level
What modalities does the dorsal column, medial lemiscal pathway mediate?
Fine touch, proprioception, vibration
Where does the dorsal column decussate?
Medulla
What is the difference between complete and incomplete spinal cord compression?
Complete- everything is damaged
Incomplete- some residual motor/sensory function preserved.
What can cause acute spinal cord compression?
Trauma
Tumours- via haemorrhage or collapse
Infection
Spontaneous haemorrhage
What can cause chronic spinal cord compression?
Degenerative disease e.g. spondylosis
Tumours
Rheumatoid arthritis
What is spinal shock?
Flaccid paralysis- in an acute injury you don’t get upper motor neuron signs initially which is spinal shock.
What is Brown Seqaurd syndrome?
Half of the cord becomes sectioned/cut
Ipsilateral motor level
Ipsilateral dorsal column
Contralateral spinothalmic
e.g. if you cut the right side of the cord, you wipe out the right side of the corticospinal tract therefore you get paralysis of the right side of the body.
You also cut the right side of the dorsal column and therefore get right sided sensory loss.
You cut the right side of the spinothalamic tract however because they decussate when they reach the spinal level, you get contralateral symptoms of pain, temp and coarse touch.
What causes central cord syndrome?
Caused by a hyeprflexion or hyperextension injury to an already stenotic neck. The central canal is already calcified and slightly stenosed.
What is a central cord syndrome?
Caused by a hyeprflexion or hyperextension injury to an already stenotic neck. The central canal is already calcified and slightly stenosed so the bit of spinal cord that is already pinched becomes more pinched momentarily. The blood supply is often compromised a bit and the central part of the spinal cord is furthest away from the blood therefore becomes ischaemic.
Why is only the upper limb affected in central cord syndrome?
the upper limb has the most medial fibres.
Which pathways are usually affected in central cord compression?
Corticospinal tract
Spinothalamic
(Dorsal column is usually preserved).
Why is the spinothalamic tract affected in central cord syndrome?
The fibres cross the midline of the spinal cord to synapse in the anterior horn. Therefore they go through an area of ischaemia.
What things can cause spinal cord compression?
Trauma- high energy injuries. Places effected are especially the mobile segments of the spine e.g. cervical spine
Tumours- extradural and intradural. Extradural are usually metastases.
How can tumours cause acute and chronic spinal cord compression?
Acute- by haemorrhage or collapse
Chronic- slowly growing.
What can cause spinal canal stenosis?
Osteophyte formation
Bulging intervertebral discs
Facet joint hypertrophy
Subluxation
Also infection- causing epidural abscesses (usually bloodborne staph or tuberculosis)
Haemorrhage- epidural, subdural, intramedullary.
Treatment of spinal cord stenosis caused by trauma?
Immobolise
Investigate
Decompress + stabilise
How would you treat metastatic tumours causing spinal cord compression?
Depends on the tumour.
How would you treat primary tumours causing spinal cord compression?
Surgical excision.
