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Intracranial haemorrhage

Extradural Haemorrhage

This is usually caused by trauma to the pterion, leading to rupture of MMA (middle meningeal artery). It classically presents with a lucid interval, followed by acute severe headache and a rapid deterioration in GCS.


N.B. Lucid interval occurs as the haematoma grows large enough to cause a large rise in ICP.


CT head will show a Bi-convex/Lens-shaped haematoma that's limited to the cranial sutures.


Management - Neurosurgical intervention

“non-contrast CT scan of an acute epidural hematoma, right fronto-temporal area, due to trauma” © Jpogi CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/)

Subdural Haemorrhage

This is more common in the Elderly and Alcoholics as they tend to have more cerebral atrophy, therefore making the bridging vessels in the dura more likely to tear and rupture. It presents with a gradually increasing headache and confusion.


CT head will show a Crescent-shaped haematoma that's not limited to the cranial sutures.


Management - Neurosurgical intervention if severe haemorrhage and symptomatic

“Large left sided frontal parietal subdural hematoma with associated midline shift” © James Heilman, MD CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/)

Subarachnoid Haemorrhage

This is usually caused by the rupture of a berry aneurysm in the Circle of Willis. It presents with:

  • Thunderclap headache - Sudden, severe occipital headache that typically comes on during strenuous activity

  • Meningism - Neck stiffness, Photophobia

  • N+V

  • Visual changes

  • Neurological symptoms - LOC, dysphasia, weakness, seizures


Differentials - Meningitis, Migraine, Intracerebral haemorrhage


Investigations:

  • CT head - Hyper-attenuation in subarachnoid space that expands bilaterally

    • If -ve but presentation very suggestive of a SAH, do a Lumbar Puncture - Look for Xanthochromia (yellowing of CSF due to haemolysis)

    • LP should be done at least 12 hours after onset of symptoms.


N.B. The initial LP may have blood due to trauma. To differentiate this from a true SAH is to do a repeat sample. A drop in the RBC count → trauma. No drop in RBC count → SAH.


General Management - Neurosurgical intervention


Management of the Complications:

  • Cerebral Ischaemia - Oral Nimodipine that prevents vasospasm, which can result in brain ischaemia

  • Re-bleeding - Endovascular coiling or surgical clipping to treat aneurysms

  • Hydrocephalus - LP or shunt insertion

  • Seizures - Anti-epileptics

“A subarachnoid hemorrhage.” © James Heilman, MD CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/)

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