Neurological disease in a child: Cerebral haemorrhage Flashcards
Define cerebral haemorrhage.
Bleed inside the extradural, subdural, or subarachnoid space
Explain the aetiology of an extradural cerebral haemorrhage.
Direct head trauma causing arterial or venous bleeding, specifically the middle meningeal artery over the temporal bone.
Explain the aetiology of a subdural cerebral haemorrhage.
Birth trauma, forceps delivery, low-birth weight infants, high falls, and non-accidental injury caused by shaking.
Tearing of the veins between the arachnoid and pia mater can give rise to chronic subdural. Acute subdural haemorrhage may occur in neonates by rupture of the vein of Galen.
Explain the aetiology of a subarachnoid cerebral haemorrhage.
Ruptured berry aneurysm or arteriovenous malformation.
Saccular or berry aneurysm arise because of haemodynamic stress in intracranial arteries that are susceptible (e.g. Ehlers-Danlos syndrome, Marfan syndrome).
What may cerebral haemorrhage be exacerbated by?
Coagulopathy
Summarise the epidemiology of extradural cerebral haemorrhage.
In children 50% occur < 2 years.
M: F = 4:1
Summarise the epidemiology of subdural cerebral haemorrhage.
Mainly occur in young infants.
Summarise the epidemiology of subarachnoid cerebral haemorrhage.
Rare in children.
What are signs and symptoms of raised intracranial pressure?
All intracranial haemorrhage may develop symptoms and signs of raised ICP as in all cases there is accumulation of blood within a closed cavity.
Early signs of raised ICP: Nausea, vomiting, confusion, drowsiness.
Late signs of raised ICP: Cushing response (increase BP, decrease HR), ipsilateral third nerve palsy, papilloedema, coma.
What are signs and symptoms of extradural cerebral haemorrhages?
History of trauma, force and site of impact, severe headache, boggy haematoma.
What are signs and symptoms of subdural cerebral haemorrhages?
Acute subdural: Shock, seizures and coma, retinal haemorrhages
Chronic subdural: Macrocephaly, failure to thrive, developmental delay
What are signs and symptoms of subarachnoid haemorrhage?
Sudden-onset occipital headache, retinal haemorrhages, neck stiffness, fever, seizures and progression to coma
What are appropriate investigations for cerebral haemorrhage?
Bloods: FBC, clotting screen Skull X-ray: May show fracture, particularly over temporal bone region. Not usually indicated as CT is preferable mode of imaging.
CT: Best modality for detecting blood in the extradural/subdural space or CSF.
Lumbar puncture: Xanthochromia (subarachnoid)
Angiography: May show aneurysms or AV malformation in subarachnoid haemorrhage
What are indications for doing a CT in a child?
- Witnessed loss of consciousness or amnesia (antegrade or retrograde) lasting > 5 minutes
- Abnormal drowsiness: Pediatrics GCS < 15 in 1 year or < 14 in > 1 year in emergency department
- >=3 discrete episodes of vomiting
- Clinical suspicion of non-accidental injury
- Post-traumatic seizure but no history of epilepsy
- Suspicion of open or depressed skull injury or tense fontanelle
- Signs of basal skull fracture (haemotympanum, panda eyes, cerebrospinal fluid leakage from ears or nose, Battle’s sign
- Focal neurological deficit
- Age < 1 year: presence of bruise, swelling or laceration > 5cm on the head
- Dangerous mechanism of injury
What is the general management for a cerebral haemorrhage?
Cervical spine immobilisation: If traumatic mechanism of head injury
Supportive care: Ventilatory support and blood transfusions if shocked
Treatment of increased ICP: 30% head of bed elevation, mannitol, hypertonic saline
