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12.11.09 Intracranial haemorrhage

Extradural haematoma
  • Trivial trauma can => EDH in kids


Subdural haematoma
  • Acute SDH normally results from more severe injury than EDH

Subarachnoid haemorrhage
  • Consider the possibility that a traumatic SAH may actually be aneurysmal
    • Which then caused the car crash, fall, etc
  • Perimesencephalic nonaneurysmal hemorrhage (PMH)
    • Subarachnoid blood accumulates around the midbrain
    • From perimesencephalic VEINS
      • => Angiogram -ve
    • Generally very good prognosis
  • Aneurysmal SAH
    • 15-20% mortality at outset
    • 50% 6 month mortality
    • 30% of survivors left with severe disability
    • 1% per day rebleed risk
      • Which have much higher mortality (70-80%)
  • Aneurysm generally continues until the rising ICP stops bleeding by tamponading the brain
  • Management
    • Coil or clip aneurysms to prevent re-bleed
    • Give IV fluids
      • May increase oedema but this risk is outweighed by the benefit of maintaining CPP
    • Nimodipine
      • Dihydropyridine calcium channel blocker
      • Some selectivity for cerebral vasculature
      • Prevents vasospasm (not sure how)
    • Fludrocortisone to prevent salt wasting
    • DON'T diagnose vasospasm until everything else has been ruled out


Pituitary apoplexy

  • Bleeding into/around the pituitary
    • Portal venous system = Unusual blood supply
    • => Susceptibility to haemorrhage
  • Usually occurs in the presence of a tumor of the pituitary
  • Most common initial symptom is a sudden headache, often associated with a rapidly worsening visual field defect or double vision
  • This is followed in many cases by acute symptoms caused by lack of secretion of essential hormones, predominantly adrenal insufficiency


Diffuse axonal injury
  • Reverberation of BRAINSTEM
    • => Initial brainstem responses (respiratory alteration, extension response, etc)
  • 50% have raised ICP
  • Petechial haemorrhages may be seen in white matter tracts or at grey/white interface


Cerebral contusion

  • Focal
    • Often frontal or temporal
  • Maximum swelling is at 4-5 days
    • Delayed deterioration


Cavernous haemangioma
  • Haemangioma that has relatively large blood-filled spaces
  • Do not contain tissue of the organ in which they are situated
  • May bleed spontaneously


Intraparenchymal haemorrhage
  • Management
    • BP control, but only if very high or low
    • Rarely operate
  • Outcome tends to be worse than ischaemic stroke


Cerebral amyloid angiopathy (CAA)
  • Form of angiopathy in which amyloid deposits form in the walls of the blood vessels of the central nervous system
    • Can be caused by the same amyloid protein that is associated with Alzheimer's dementia
      • => More common in people who suffer from Alzheimer's
  • The amyloid material is only found in the brain and as such the disease is not related to other forms of amyloidosis
  • Predisposes blood vessels to failure, increasing the risk of a hemorrhagic stroke


Notes
  • AVMs usually cause intraparenchymal bleeds rather than SAH
    • Low re-bleed risk (2-3% per year)
    • Treat with surgery, embolisation, stereotactic radiosurgery
  • Apoplexy = sudden neurologic impairment, usually due to a vascular process
  • HTN tends to cause multiple microaneurysms in brain
    • Only visible under microscope
  • LP can detect RBCs (acutely) or xanthochromia (12 hr later, from bilirubin) after SAH
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