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Intracranial bleed Flashcards

1
Q

First line for subarrach

A

CT head

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2
Q

Presentation of subarrachnoid haemorrhage

A

Sudden explosive headache 10/10 pain in back of head - thunderclap
Nausea and vomitting
Photophobia

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3
Q

What is seen on lumbar puncture in a subarrachnoid haemorrhage?

A

Xanthachromia

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4
Q

What is a subarrahcnoid haemorrhage?

A

Bleed into subarachnoid space between arachnoid and pia mater meningeal layers

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5
Q

Complications of SAH

A

Brain damage - hypoxia, raised ICP, direct cranial injury
Neurological disabilities
Coma
Death

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6
Q

Causes of SAH

A

Traumatic injury or spontaneous
Intracranial aneurysms
Arteriovenous malformation
Unknown
Rare disorders

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7
Q

Risk factors for spontaneous SAH

A

HPTN
Smoking
FH
Autosomal dominant PCKD
Over 50
Female

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8
Q

Clinical findings in SAH

A

reduced LOC due to raised ICP
Neck stiff - meningeal irritation
Kerniges sign

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9
Q

What is kerniges sign caused by?

A

Irritiation of motor nerve roots pass through innflamed meninges as under tension
Non specific

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10
Q

Lab investigations for SAH

A

FBC and U+Es to obtain a baseline
Coag studies - before LP/surgery

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11
Q

Imaging investiations SAH

A

Plain CT head - blood in SA space, hydrocephalus
CT angiogram - arterial vessel highlights - aneurysm

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12
Q

When is an LP necessary in SAH?

A

When SAH suspected but CT scan does not show evidence of bleeding or raised ICP

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13
Q

How quickly does an LP need to be performed after onset?

A

12 hours

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14
Q

What is xanthochromia?

A

CSF stained yellow - infiltration of blood
jbilirubin, oxyhaemoglobin from haemolysis RNCs

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15
Q

Management SAG

A

A to E
Airway - reduced LOC
B - hypoxia - oxygen
C - BP - IV fluids, electrolyte replacement - Na
CCBs MUST be given
D - intracranial pressure monitoring. Pupils dilated = blown = brainstem damage

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16
Q

Why are CCBs given in SAH?

A

eg nimodipine
To reduce cerebral artery spasm and secondary cerebral ischaemia

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17
Q

General cpmplications ICH

A

Obstructive hydrocephalus - ventricular drain
Arterial vasospasm
Re-bleeding of aneurysms
Neurological deficits
Cerebral ischaemia

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18
Q

What is an epidural haemotoma?

A

Haemorrhage between dura mater and inner surface of skull

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19
Q

Subarrach on CT

A

white in ventricles

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20
Q

Epidural on CT

A

Lemon on CT
Midline shift
Tentorial/brainstem herniation

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21
Q

Subdural on CT

A

Moon

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22
Q

How can an Epidural haemotoma cause brainstem death?

A

Raised ICP can cause cerebellar herniation -> brainstem death

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23
Q

Causes of epidural haemotoma

A

Skull traum and temporparietal region
eg fall, assault, sporting injury
Rupture of a vein - MMV or dural sinus
Arteriovenous abnormalities, bleeding disorders

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24
Q

Which part of the sull is espicially vulnerable to fracture?

A

Pterion = pariteal, sphenoid and temporal bones fuse

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25
What artery does a fracture to the pterion dmaage?
Middle meningeal artery
26
Symptoms of epidural haemotoma
Headache N+V Confusion LOC followed by period of lucidity, progressively decreasing LOC after several
27
Clinical findings in EDH
Tender skull Confusion Reduced GCS Cranial nerve deficits Motor or sensory deficits of upper and lower limbs Hyperreflexia and spasticity Upgoing plantar reflex - babainskis sign Cushings triad
28
What is cushings triad?
Raised ICP to attmept to improve perfusion -HPTN -Bradycardia Irrefular breathing pattern
29
Bedside investigationsEDH
Cap blood glucose - rule out hypoglycaemia ECG - heart block - bradycardia cause
30
Lab investigationsEDH
FBC U+Es GCS CRP Coagulation Group and save
31
Imaging investigations for intracranial bleed gold standard
CT head
32
When do you do a skull x ray?
When skull fracture to assess for evidence of EDH
33
Management of EDH
Conservative - bleed is small with miinimal mass effect Medical - Reversal of anitcoagulation, Prophylatctic antibiotics - in context of open skull fracture, mannitol, barbituates Surgical - Burr hole craniotomy, trauma craniotomy, hemicranectomy
34
Coagulopathy
Thrombocytopenia Porlonged PT
35
Agents to reduce ICP
Mannitol - IV - osmotic effect prior to surgery Barbituates - reduce ICP and protect brain from anoxia
36
Burr hole craniotomy
evacuation of the haematoma.
37
When is trauma craniotomy used?
Significant mass effect - evacuate blood, treat cause of bleeding (litigation) + reduced ICP
38
When do hemicraniectomy?
Prevent brain stem herniation + death due to raising ICP in SDH
39
Post surgical management EDH
ICP monitoring and repeat CT scans
40
Complications of EDH
Infection Cerebral ischaemia (adjacent to haemotoma) Seizures Cognitive impairment Hemiparesis Hydrocephalus (ventricle obstruction) Brainstem injury (raised ICP)
41
Types of subdural haematoma
Acute < 3 dyas Subacute 3 - 21 days Chronic > 21 days sIMPLE OR COMPLICATED - PARENCHYMAL injury or not
41
Types of subdural haematoma
Acute < 3 dyas Subacute 3 - 21 days Chronic > 21 days
42
Cause of subdural haematoma
Trauma Rupture of cerebral aneurysm Cerebral hypotension Malignancy - rare Spontaneous
43
Risk factors for developing subdural haemotama
History of trauma Co-morbidities that make patient vulnerable to falls Age over 65 Anticoagulant History of coagulopathy History of LOC Fctors that stretch bridging veins eg cerebral atrophy, low CSF pressure after shunt Alcoholism
44
Symptoms of subdural haematoma
Headache Nausea and vomitting Fluctuating consciousness level: Confusion, drowsiness, personality change, memory loss Intervening lucid periods Poor balance Weakness Paraesthesia or numbness Aphasia if on L side
45
Findings on exam for subdural haematoma
Neurological exam of CNs, upper limb and lower limb Limb weakness or sensory disturbance Cranial nerve abnormalities Ataxia Seizures Reduced LOC
46
Lab investgiations
FBC U+Es LFTs Coag studies Group and save - crossmatch
47
What do you need FBC, U+Es, LFTs and coag studies for in subdural haematoma?
FBC - identify anaemia - raised WCC U+Es - assess pre-op renal function and electrolyte abnormalities LFTs = baseline + synthetic function of liver (vit K dependent clotting factors) Coag studies - identify coagulopathy needing correction to reduce haematoma extension and allow for surgical intervention
48
Imaging investigations
Non contrast CT head - required for all intracranial bleeding sus Crescent shaped collection blood overlying one of cerebral hemispheres
49
CT appearances of SDH acute
Crescent - banana shaped Acute - hyperdense Chronic - hypodense - dissolution of liquified blood Not limited by suture lines
50
Management of subdural haematoma - medical
Correct coagulation studies - reversal agents, haematology Anticonvulsants - eg levetiracetam, phenytoin
51
Complications of SDH
Seizures Neurological deficits Recurrent haemorrhage Infection
52
ECG subarrach
Peaked P and T waves Short PR interval Prolonged QT interval tall U waves
53
When do you not perform an LP?
Sus raised ICP
54
When are CT/MRI angiographyies done in bleed?
TO find sourve of bleed in those fit for surgery
55
Classification for SAH
Hunt and HEss 1-5
56
Grades in Hunt and HEss classification for SAH
1 - asymptomatic 2 - moderate - severe headache, nuchal rigidity, CN palsy 3 - drowsy, confused, mild neurological deficit 4 - stupor, moderate to severe hemiparesis 5 - Coma, decerebrate posturing
57
Risk factors SAH
HPTN Smoking Cocaine Alcohol exceess Genetic disorders - marfans, ehlers dhanlos, NF type I, polycystuc disease 1st degree relatives
58
How does trauma cause a SDH
Teearing of bridging veins from tortex to one drainging venous sinuses - rapid acceleration decelration of head Damaged cortical artery Blunt head trauma
59
Investgiations SDH
Bloods - FBCs, U+Es, LFTs, coag screen, grouo and save/crossmatch CT head = 1st line Skull X ray MRI head
60
Chronic subdural haematoma on CT head
hypodense (dark), crescentic collection around the convexity of the brain
60
Acute to chronic subdural haematoma
Acute: Symptoms usually develop within 48 hours of injury, characterised by rapid neurological deterioration Subacute: Symptoms manifest within days to weeks post-injury, with a more gradual progression. Chronic: Common in the elderly, developing over weeks to months. Patients may not recall a specific head injury.
61
Neuro symptoms of subdural haematoma
Altered Mental Status: Ranging from mild confusion to deep coma. Fluctuations in the level of consciousness are common. Focal Neurological Deficits: Weakness on one side of the body, aphasia, or visual field defects, depending on the haematoma's location. Headache: Often localised to one side, worsening over time. Seizures: May occur, particularly in acute or expanding hematomas. ESP memory loss in elderly
61
Cushings triad raised ICP
Bradycardia HPTN resp irregularities

ENT, neuro, eyes (34 decks)

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