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