STEP 2:BRAIN BLEEDS

Question 1

A physical finding in which forced flexion of the neck elicits an involuntary flexion of the knees and hips. It can occur in patients with meningeal irritation secondary to meningitis or subarachnoid hemorrhage.

Answer 1

Brudzinski’s sign

Question 2

Sudden-onset severe headache with meningeal signs (Brudzinski sign, nausea, vomiting, fever) and the CT scan findings of hyperdensity in the basal cistern suggest…

Answer 2

subarachnoid hemorrhage.

Subarachnoid hemorrhage in the basal cisterns
CT head (without contrast; axial plane)

Hyperdensity (green overlay) in the basal cisterns indicates the presence of subarachnoid hemorrhage.

Question 3

the most common cause of nontraumatic subarachnoid hemorrhage (SAH)

Answer 3

Ruptured aneurysms

Surgical clipping or endovascular coiling are used in the treatment of aneurysms to prevent rebleeding; the choice of option is based on a variety of factors, such as the location and size of the aneurysm, severity of neurological deficits, and the patient’s age.

Question 4

In a pt with a subarachnoid hemmorhage, when would you consider a craniotomy?

Answer 4

If they are unstable!

A decompressive craniectomy may be used to decrease intracranial pressure in patients with subarachnoid hemorrhage if they are at increased risk of cerebral herniation. This patient is hemodynamically stable and does not have cranial nerve palsies or evidence of a midline shift on CT scan to suggest that she is at increased risk of herniation.

craniotomy, not burr hole Burr hole surgery may be indicated for the treatment of subdural hematoma

Question 5

When do we use Burr hole surgery?

Answer 5

Burr hole surgery may be indicated for the treatment of subdural hematoma, which may manifest with headache, nausea, and vomiting.

Question 6

Answer 6

Subdural hematoma and cerebral edema
CT head (without IV contrast; axial section; brain window) of a patient with a history of trauma

A large acute subdural hematoma is visible as a hyperdense crescent-shaped lesion along the lateral aspect of the left hemisphere (red overlay). It is accompanied by an extracranial soft tissue hematoma (hatched red overlay). There is extensive hypodense left cerebral edema (gray overlay), with sulcal effacement and shift of midline structures (green line) to the right. The anterior horns of the lateral ventricles (hatched green overlay) are compressed and the posterior horn of the right lateral ventricle (red circle) is dilated.

Question 7

The type of bleed that is bound by the cranial sutures is

Answer 7

The type of bleed that is bound by the cranial sutures is an epidural hematoma (EDH)

Question 8

How do we prevent rebleeding in SAH?

Rebleeding is a life-threatening complication that most commonly occurs in the first 6 hours after SAH. Start measures to prevent rebleeding immediately.

Answer 8

Anticoagulant reversal
Management of blood pressure and cerebral perfusion pressure (CPP): See “Blood pressure control in brain injury” for a general approach. .
Target SBP < 160 mm Hg (reasonable for patients with aneurysmal SAH) [18]
Suspected increased ICP: Consider permissible hypertension (e.g., MAP > 90 mm Hg) to maintain cerebral perfusion pressure and prevent cerebral hypoperfusion. [41][42]
Control symptoms that can increase ICP: Administer pain management and antiemetics as needed. [20]
Antifibrinolytic therapy: not routinely recommended