Intracranial haemorrhages

• What are the four types of intracranial haemorrhage?

  Extradural

  Subdural

  Subarachnoid

  Intracerebral
• Where is extradural bleed located?

  Between skull and dura mater
• Where is subdural bleed located?

  Between dura mater and arachnoid mater.
• Where is subarachnoid haemorrhage located?

  Subarachnoid space which is between pia mater and arachnoid membrane.
• Where is intracerebral bleed located?

  Brain tissue
• Give 8 risk factors for brain bleeds

  Head injuries

  Hypertension

  Aneurysms

  Ischaemic strokes

  Brain tumours

  Thrombocytopenia

  Bleeding disorders

  Anticoagulants
• What is the presentation of brain bleeds?

  Sudden onset headache

  Seizures

  Vomiting

  Reduced consciousness

  Focal neurological symptoms such as weakness
• What are the 3 pillars of glasgow coma scale?

  Eyes

  Verbal response

  Motor response
• What is the maximum and minimum GCS score?

  15/15 to 3/15
• At what GCS score needs airway support?

  8/15
• Why does a patient with a GCS score of 8 need airway support?

  Airway obstruction can lead to aspiration, hypoxia and brain injury.
• Give the 4 levels of Eye responses in GCS

  4 - Spontaneous

  3 - Speech

  2 - Pain

  1 - None
• Give the 5 levels of verbal response in GCS

  5 - Oriented

  4 - Confused

  3 - Inappropriate words

  2 - Incomprehensible sounds

  1 - None
• Give the 6 levels of motor response in GCS

  6 - Obey's commands

  5 - Localises pain

  4 - Normal flexion

  3 - Abnormal flexion

  2 - Extends

  1 - None
• Which artery is ruptured in extradural haemorrhage?

  Middle meningeal artery
• Which fracture is extradural haemorrhage associated with?

  Temporal bone
• What would you see on CT of extradural haemorrhage?

  Biconvex shape
• What is the typical history of extradural bleed?

  Young patient

  Traumatic head injury

  Ongoing headache

  Period of improved neurological symptoms and consciousness

  Followed by rapid decline after hours as haematoma compresses the brain
• What causes subdural haemorrhage?

  Rupture of bridging veins
• What would you see on CT in subdural haemorrhage?

  Crescent shape
• Which two type of patients are most likely to get subdural haemorrhage? Why?

  Elderly patients

  Alcoholic patients

  They have more atrophy in their brains making the vessels more prone to rupture.
• What lies in the subarachnoid space?

  CSF
• What causes subarachnoid haemorrhage?

  Ruptured aneurysm due to strenuous activity.
• What is the presentation of subarachnoid haemorrhage?

  Sudden onset, occipital headache, known as a thunderclap headache.
• How does an intracerebral haemorrhage present?

  Sudden onset focal neurological symptoms such as limb or facial weakness, dysphasia or vision loss.
• How do intracerebral haemorrhages occur?

  Spontaneously

  Or secondary to ishcaemic stroke, tumours or aneurysm rupture.
• What are the principles of management for major brain bleeds?

  Admit to stroke centre

  Discuss with specialist neurological centre to consider surgical treatment

  Consider intubation, ventilation and intensive care if they have reduced consciousness

  Correct clotting abnormalities

  Correct severe hypertension
• How would you manage a small brain bleed?

  Can be conservative management such as close monitoring and repeat imaging.

  Surgical options such as craniotomy or burr holes may be considered.