Week 5- intracranial haemorrhage and spinal cord compression

Question 1

What sort of aneurysm usually underlies subarachnoid haemorrhages?

Answer 1

Berry aneurysm

Question 2

Presentation of subarachnoid haemorrhage?

Answer 2

Sudden onset headache- one second its normal and the next you have an excruciating headache. 
Collapse
Vomiting
Neck pain
Photophobia

Question 3

What are the differential diagnosis of sudden onset headache?

Answer 3

Subarachnoid headache
Migraine
Benign coital cephalgia

Question 4

Signs in subarachnoid haemorrhage?

Answer 4

Focal neurological deficit (dysphagia, hemiparesis, third nerve palsy)
Fundoscopy- retinal or vitreous haemorrhage
Decreased conscious level
Photophobia
Neck stiffness

Question 5

What will a CT scan of the brain in SAH show?

Answer 5

May be negative if >3 days.
CSF is constantly being generated and absorbed so if the patient comes in straight away- there will be obvious blood on the CT. However if you wait a few days you may not see blood.

Question 6

What colour is the CSF normally on CT and what happens to it in subarachnoid haemorrhage?

Answer 6

Normally the CSF is blackish on CT because its low density. However blood shows up white.

Question 7

When is lumbar puncture safe in subarachnoid haemorrhage?

Answer 7

Safe in alert patient with no focal neurological deficit and no papilloedema. Or after a normal CT scan.

Question 8

What will a lumbar puncture of a subarachnoid haemorrhage show?

Answer 8

Blood stained or xanthochromic CSF.

Question 9

How would you differentiate from a traumatic tap and a subarachnoid haemorrhage?

Answer 9

Take three small CSF samples labelled one to three. If the blood is less in the third one than the first one then its a traumatic tap. The CSF slowly washes the blood away.
If the blood is consistent- then its a subarachnoid.

Question 10

What other investigations once you’ve confirmed a subarachnoid haemorrhage would you do?

Answer 10

A cerebral angiography. Gold standard treatment- however small chance an aneurysm will be missed due to vasospasm.

Question 11

Name some complications of subarachnoid haemorrhage

Answer 11

Re-bleeding
Delayed ischaemic deficit 
Hydrocephalus
Hyponatraemia 
Seizures

Question 12

What techniques stop re-bleeding?

Answer 12

Endovascular techniques

Surgical clipping is rarely done.

Question 13

What is delayed ischaemic deficit?

Answer 13

Sometimes known as vasospasm.

All it means is the brain becomes ischaemic in areas.

Question 14

When does delayed ischaemic deficit usually present?

Answer 14

3-12 days.

Question 15

What is the treatment for delayed ischaemic deficit?

Answer 15

Give nimodipine

Triple H therapy- hypervolaemia, hypertension and haemodilution.

Question 16

What does delayed ischaemic deficit look like on CT?

Answer 16

The dead brain tissue looks black.

Question 17

What is the treatment for hydrocephalus?

Answer 17

CSF drainage- could be lumbar puncture or shunt.

Question 18

What is the management of hyponatraemia in subarachnoid haemorrhage patients?

Answer 18

Give sodium supplementation- do not fluid restrict.

Question 19

What is an intracerebral haemorrhage?

Answer 19

Bleeding into the brain parenchyma.

Question 20

What causes intracerebral haemorrhage?

Answer 20

50% are due to hypertension

30% due to aneurysms or AVM.

Question 21

Describe the process of hypertension causing intracerebral haemorrhage? What does this result in?

Answer 21

Tiny aneurysms (Charcot Bouchard micro aneurysms) on blood vessels occur due to degenerative mechanisms from hypertension. This results in basal ganglia haematoma.

Question 22

Presentation of intracerberal heamorrhage?

Answer 22

Headache- not as bad or sudden as subarachnoid haemorrhage

Focal neurological deficit- hemiplegia or hemiparesis is likely to be it.

Question 23

Which investigations would you do into intracerebral haemorrhage?

Answer 23

CT scan- urgent if decreased conscious level.

Angiography if suspicion of underlying vascular abnormality.

Question 24

Treatment of intracerebral haemorrhage?

Answer 24

Surgical evacuation of haematoma +/- treatment of underlying abnormality.
Non-surgical management

Question 25

When does an intraventricular bleed occur?

Answer 25

Rupture of a subarachnoid or intracerberal haemorrhage into the ventricles.

Question 26

What is an arteriovenous shunt?

Answer 26

An abnormal connection between an artery and vein. They are much rarer than aneurysms. Also known as AVMs

Question 27

How would you treat an AVM?

Answer 27

Surgery Endovascular embolisation Stereotactic radiotherapy

Question 28

Where does the upper motor neurone originate from and end in the corticospinal tract?

Answer 28

Originates in the motor cortex. | Ends in the grey matter of the anterior horn

Question 29

Where do pathways decussate in the corticospinal tract ?

Answer 29

Medulla

Question 30

What signs will show in an upper motor neurone lesion?

Answer 30

Increased tone Brisk reflexes No fasciculation Muscle wasting not marked.

Question 31

What signs will show in an lower motor neurone lesion?

Answer 31

Decreased tone Muscle wasting Fasciculation Diminished reflexes.

Question 32

What modalities does the spinothalmic pathway mediate?

Answer 32

Pain, temperature and crude touch.

Question 33

Is the corticospinal tract contralateral or ipsilateral?

Answer 33

Ipsilateral

Question 34

Is the spinothalamic pathway contralateral or ipsilateral?

Answer 34

Contralateral

Question 35

When does the spinothalamic tract decussate?

Answer 35

At spinal level

Question 36

What modalities does the dorsal column, medial lemiscal pathway mediate?

Answer 36

Fine touch, proprioception, vibration

Question 37

Where does the dorsal column decussate?

Answer 37

Medulla

Question 38

What is the difference between complete and incomplete spinal cord compression?

Answer 38

Complete- everything is damaged | Incomplete- some residual motor/sensory function preserved.

Question 39

What can cause acute spinal cord compression?

Answer 39

Trauma Tumours- via haemorrhage or collapse Infection Spontaneous haemorrhage

Question 40

What can cause chronic spinal cord compression?

Answer 40

Degenerative disease e.g. spondylosis Tumours Rheumatoid arthritis

Question 41

What is spinal shock?

Answer 41

Flaccid paralysis- in an acute injury you don't get upper motor neuron signs initially which is spinal shock.

Question 42

What is Brown Seqaurd syndrome?

Answer 42

Half of the cord becomes sectioned/cut Ipsilateral motor level Ipsilateral dorsal column Contralateral spinothalmic e.g. if you cut the right side of the cord, you wipe out the right side of the corticospinal tract therefore you get paralysis of the right side of the body. You also cut the right side of the dorsal column and therefore get right sided sensory loss. You cut the right side of the spinothalamic tract however because they decussate when they reach the spinal level, you get contralateral symptoms of pain, temp and coarse touch.

Question 43

What causes central cord syndrome?

Answer 43

Caused by a hyeprflexion or hyperextension injury to an already stenotic neck. The central canal is already calcified and slightly stenosed.

Question 44

What is a central cord syndrome?

Answer 44

Caused by a hyeprflexion or hyperextension injury to an already stenotic neck. The central canal is already calcified and slightly stenosed so the bit of spinal cord that is already pinched becomes more pinched momentarily. The blood supply is often compromised a bit and the central part of the spinal cord is furthest away from the blood therefore becomes ischaemic.

Question 45

Why is only the upper limb affected in central cord syndrome?

Answer 45

the upper limb has the most medial fibres.

Question 46

Which pathways are usually affected in central cord compression?

Answer 46

Corticospinal tract Spinothalamic (Dorsal column is usually preserved).

Question 47

Why is the spinothalamic tract affected in central cord syndrome?

Answer 47

The fibres cross the midline of the spinal cord to synapse in the anterior horn. Therefore they go through an area of ischaemia.

Question 48

What things can cause spinal cord compression?

Answer 48

Trauma- high energy injuries. Places effected are especially the mobile segments of the spine e.g. cervical spine Tumours- extradural and intradural. Extradural are usually metastases.

Question 49

How can tumours cause acute and chronic spinal cord compression?

Answer 49

Acute- by haemorrhage or collapse | Chronic- slowly growing.

Question 50

What can cause spinal canal stenosis?

Answer 50

Osteophyte formation Bulging intervertebral discs Facet joint hypertrophy Subluxation Also infection- causing epidural abscesses (usually bloodborne staph or tuberculosis) Haemorrhage- epidural, subdural, intramedullary.

Question 51

Treatment of spinal cord stenosis caused by trauma?

Answer 51

Immobolise Investigate Decompress + stabilise

Question 52

How would you treat metastatic tumours causing spinal cord compression?

Answer 52

Depends on the tumour.

Question 53

How would you treat primary tumours causing spinal cord compression?

Answer 53

Surgical excision.