Intracranial Haemorrhages

Question 1

How can Intracranial Haemorrhages be sub-catagorised?

Answer 1

Extra-axial and Intra-axial haemorrhage

Question 2

What is an Extra-axial Haemorrhage? - Give examples

Answer 2

A haemorrhage that occurs within the skull but outside the Brain tissue
e.g.
- Epidural.
- Subdural.
- Subarachnoid.

Question 3

What is an Intra-Axial Haemorrhage? - Give examples

Answer 3

A haemorrhage occurring within the Brain tissue itself.
e.g.
- Intracerebral.
- Intraventricular.

Question 4

What layers are an Epidural haemorrhage between?

Answer 4

Dural membrane and bone.

Question 5

How do Epidural Haemorrhages occur?

Answer 5

Often trauma related (70-95% present with skull fracture)
- RTA, Falls, Assault

Question 6

What is the most common source of blood in Epidural Haemorrhages?

Answer 6

Blood is most often arterial (e.g. Middle Meningeal A.)

Question 7

How would a Patient with an Epidural Haemorrhage present clinically?

Answer 7

• Altered consciousness
  PERIODS OF LUCIDITY and UNCONSCIOUSNESS.
• Headache
• Vomiting
• Confusion / Seizures
• Aphagia (Inability to swallow)

Question 8

What would an Epidural Heamorrhage be described as on CT.

Answer 8

A biconcave Lens
(Limited to the skull sutures where the dura adheres to the skull)

Question 9

What is the management of an Epidural Haemorrhage?

Answer 9

Depends on the severity.
Can vary from observations and monitoring to immediate surgical evacuation.

Question 10

What layers do subdural Haemorrhages occupy?

Answer 10

Bleeding occurs between the Dura and Arachnoid membrane.

Question 11

What is the likely cause of Subdural haemorrhages?

Answer 11

Head trauma related.
- RTA, Assault, Falls.

Question 12

What is the source of the bleeding in Subdural Haemorrhages?

Answer 12

Bleeding occurs as a result of tearing of the Bridging veins.

Question 13

What clinical manifestations would a patient presenting with Subdural Haemorrhage exhibit?

Answer 13

Similar to Epidural (confusion, nausea/vomiting)
However typically older patient >65.
50% present with coma.
coning may follow.
Epilepsy occasionally occurs.

Neurological decline common.

Question 14

What would be seen on CT with a Subdural Haemorrhage?

Answer 14

A crescent of blood around the brain tissue, with midline shift.
- Follows the contour of the skull as it is not restricted by skull sutures.

If absent but still suspicious check CSF cause there will be blood in this.

Question 15

What is the management of Subdural haemorrhages?

Answer 15

Close monitoring.
Even large collections can resolve spontaneously.
If draining required:
- Acute haemorrhage: Craniotomy.
- Chronic Haemorrhage: Burr holes.

Question 16

What layers are subarachnoid Haemorrhages between?

Answer 16

In the subarachnoid space (between Arachnoid membrane and Pia matter)

Question 17

What are the likely causes of SAH?

Answer 17

Spontaneous arterial bleeding into the Subarachnoid space. (Accounts for 5% of strokes)
Causes of bleeding:
- Saccular (berry) aneurysms most common. (Cerebral A.)
- Arteriovenous malformation.
- Rare associations with bleeding disorders, tumours, Marfans or Ehlers-Danlos.

Question 18

What are the Clinical Features SAH?

Answer 18

Sudden very severe headache. “thunderclap headache”
- Loss of Consciousness / Seizure
- nausea / vomiting.
- Coma

Meningismus - Following severe SAH, Stiff neck and positive kernig’s sign (like Meningitis).

Question 19

What are the Investigations for SAH?

Answer 19

CT.

Can Do LP if High clinical suspicion but negative CT - 12hrs post onset.
- Blood present (pink CSF)
- yellowing of CSF due to haemolysis in older bleeds (Xanthochromia)
- Increase in CSF bilirubin.

• If patient presents after 8 hours, a negative CT scan does not rule out a SAH.

Question 20

What is seen on CT of SAH?

Answer 20

Irregular shaped bleed, hyperattenuation in the subarachnoid space that expands bilaterally.

Question 21

What is the management for SAH.

Answer 21

• Control Hypertension.
• Bed rest and supportive measures.
• Nimodipine (a CCB) reduces mortality - prevents vasospasm, thus optimising cerebral perfusion.

Question 22

What are the causes of Intracerebral haemorrhages?

Answer 22

• Hypertension.
• Embolism.
• Brain Tumour.
• Bleeding Disorder.
• Drugs. (Oral Anticoagulants require investigation in severe headache regardless)

Question 23

How would Intracerebral haemorrhages present clinically?

Answer 23

The Neurological signs and Symptoms depend on the are affected.
- Headache.
- Nausea / Vomiting.
- Decreased consciousness level.

Associated with coma and severe headache.

Question 24

What is the treatment of Intracerebral haemorrhages?

Answer 24

• Essentially supportive
• Surgical decompression probably most beneficial to patient with lobar haemorrhage

Question 25

What are Intraventricular Haemorrhages?

Answer 25

Bleeding Confined to the ventricular system of the brain.

Question 26

What is the Aetiology of Intraventricular Haemorrhages?

Answer 26

• Occurs as a secondary phenomenon when intracerebral haemorrhage ruptures.
  Or When SAH extends to the ventricles.