Haemorrhage

Question 1

What is the clinical presentation for a subarachnoid haemorrhage?

Answer 1

1) Sudden + severe occipital headache (thunderclap)
2) Vomitting
3) Neck stiffness (Kernig’s sign after 6 hours)
4) ALOC (drowsiness, collapse, seizures, coma)
5) Papilloedema
6) Focal neurology
7) Retinal bleed
8) Sentinel Headache

Question 2

What investigations would you do for an SAH? What would you see?

Answer 2

1) CT Scan - star-shaped lesion

2) LP - If CT is normal but SAH is suspected, bloody early, yellow (xanthochromic several hours after)

Question 3

How would you treat SAH?

Answer 3

1) Medical emergency - refer to neurosurgery ASAP.
2) Maintain cerebral perfusion - keep hydrated + dexamethasone to decrease cerebral oedema.
3) Nimodipine (CCB) - reduce vasospasm.
4) Surgery - Endovascular coiling or surgical clipping.

Question 4

Complications of SAH?

Answer 4

1) Rebleeding
2) Cerebral Ischaemia (due to vasospasm)
3) Hyponatraemia
4) Hydrocephalus

Question 5

What are 5 risk factors for Subdural haematoma?

Answer 5

1) Traumatic Head Injury
2) Increasing age (cerebral atrophy makes bridging veins vulnerable)
3) Anticoagulant medication
4) Alcoholism (Cerebral atrophy)
5) Physical abuse in infant

Question 6

What are the signs and symptoms for a Subdural Haematoma?

Answer 6

If Acute:
1) Fluctuating levels of consciousness
2) Raised ICP with headache, vomitting, nausea, raised BP)
3) Seizures
4) Confusion
5) Focal signs - hemiparesis/unequal pupils
If Chronic:
1) Cognitive Decline
2) Personality change

Question 7

What investigations would you do for a SDH?

Answer 7

1) CT/MRI - shows hyper dense crescent shaped mass over 1 hemisphere. Differentiates from EDH.
(Will eventually become hypodense as clot ages due to protein degradation)

Question 8

Treatment for SDH?

Answer 8

1) Assess and manage ABC’s + prioritise CT.
2) Refer to neurosurgeons - Burr twist drill + burr hole craniotomy.
3) IV Mannitol to reduce ICP
4) Address cause of trauma - fall due to cataract etc.

Question 9

What causes an extradural haemorrhage?

Answer 9

Trauma to the temple or parietal bone causing a bone fracture and laceration of the middle meningeal artery.

Question 10

What is the clinical presentation for an EDH?

Answer 10

1) Brief post-traumatic loss of consciousness
2) Lucid interval for several hours or days followed by deteriorating consciousness.
3) Rapid increase in ICP - nausea, vomitting headache
4) Seizures and confusion
5) Hemiparesis with brisk reflexes
7) Transtentorial coning - ipsilateral dilated pupil, tetraplegia, respiratory arrest due to brainstem compression

Question 11

What investigations are done for a suspected EDH?

Answer 11

1) CT - gold standard showing hyper dense biconvex/lens shape adjacent to skull
2) X-ray shows fracture line
3) LP is contraindicated

Question 12

How do you treat an EDH?

Answer 12

1) Medical emergency - assess and stabilise with ABCDE.
2) Refer to Neurosurgery for clot evacuation and ligation of bleeding vessel.
3) IV Mannitol to decrease ICP