Intracranial Haematoma and the Aphasias

Subdural Haematoma

Underneath dura, above arachnoid

venous, slow to develop into a mass because of slow leakage of veins

Acute subdural haematoma characteristics

rapid effects, raid rise in ICP

patient appears drowsy and confused

pupils are dilated and fixed

Subacute subdural hematoma onset and characteristics

occurs within 2-14 days of injury

cannot regain consciousness

What does the breakdown of subdural hematoma cause?

increased ICP (broken down by enzymes, number of molecules increases, much more space is being occupied, thus we have increased ICP)

Chronic subdural hematoma characteristics

develops weeks or even months after a “minor” head injury

can be misdiagnosed as dementia

How can one diagnose a head injury?

CT scan, MRI, cervical spine x-ray, GCS

in an emergency : craniotomy, craniectomy, cranioplasty, Burr-hole

Craniotomy

small hole is made in the skull or a piece of bone from the skull is removed to show part of the brain (immediately replaced)

Craniectomy

a piece of the skull is removed and not immediately replaced to relieve pressure on the brain

Cranioplasty

repair or replace a part of the skull that was removed — usually after a craniectomy (either the original bone or a synthetic one)

Burr-hole

a small hole drilled into the skull

What is the common cause of a Subarachnoid Haemorrhage?

Rupture of an aneurysm in the circle of Willis

Most common site of subarachnoid haemorrhage?

Anterior cerebral and anterior comminating arteries

Epidemiology of Subarachnoid Haemorrhage

Higher in women

risk factors : hypertension, smoking, alcohol abuse, cocaine use (since it increased BP)What

What does Familial polycystic kidney disease have to do with SAH?

People with polycystic kidney disease have a higher chance of developing intracranial aneurysms, so there is also a high risk of that aneurysm rupturing

Clinical features of SAH

Headache, vomiting, cranial nerve III paralysis (because its the longest - oculomotor)

Clinical features of Acute SAH?

Pt presents with neck stiffness, inability to look at light (might ask you to turn the lights off/down) and a positive Kernig’s sign

“worst headache of their lives”

Kernig’s sign

Kernig’s sign is positive when straightening the knee while the hip is bent at 90° causes pain or resistance in the back or neck

In what state is the CSF in SAH?

Blood stained - because when an aneurysm happens, blood enters the subarachnoid space and mixes with the CSF
(blood stained if its done early on, yellow if done 12 hours to 2-3 later)

Which one do we perform first? CT or lumbar puncture?

CT. If the CT scan comes back negative, then we can perform a lumbar puncture

Anti-fibrinolytic therapy

Reduces re-bleeding that may occur 2 hours after the initial haemorrhage

Why are clipping and coiling performed?

To treat cerebral aneurysms that their rupture can potentially lead to SAH

What are some complications that can follow SAH?

Re-rupture, Cerebral vasospasm, Hydrocephalus

Re-rupture characteristics

First 4 weeks

Sudden severe headaches, vomiting, unconsciousness

Cerebral vasospasm

4-15 days

can cause cerebral infraction

Hydrocephalus

2-3 weeks

Gait disturbance (way of walking is fucked up), urinary incontinence, dementia

SAH investigation order

CT
Lumbar Puncture

DSA

MRA, CTA

Treatment of SAH

Bed rest for 4-6 weeks

Prevent activities that can spike up the BP and increase ICP (i.e excitement, constipation)
Medication and antifibrinolytic drugs (EACE)

Lumbar puncture to replace CSF

Medication to reduce ICP

Mannitol

Medication to reduce cerebrovascular spams

Nimodipine and flunarizine

Where does the Epidural (Extradural) haemorrhage occur?

Between the skull and dura matter

Where can you find the middle meningeal artery?

temporal bone groove, inner aspect of the temporal bone

What conditions can fuck up the middle meningeal artery?

A blow to the side of the face

What happens when the middle meningeal artery is affected?

It bleeds into the epidural space

What are the characteristics of an Epidural Hemorrhage?

Initial confusion, low/loss consciousness

Lucid interval (a brief period where the pt seems to be their normal selves)

Change in mental status, unstable vital signs (BP, HR)

What is the body’s response to increased ICP?

Increased BP, decreased HR, decreased resp rate

How can increased ICP affect the brainstem?

Compresses blood vessels, blocks of oxygen delivery causing ischaemia and the puts pressure on the brainstem

Cushing’s Triad

1. Hypertension

2. Brachycardia

3. Decreased Resp Rate

What do you do when Cushing’s Triad is present?

Increase MAP, decrease ICP, monitor and control

What does the Hypothalamus do when MAP < ICP?

It activates CNS ischaemic response reflex

Under what conditions is blood flow to the brain restored?

MAP>ICP

Expressive (Nominal) Dysphasia and affected area

Failure to name an object but with recognition of the correct answer

Dominant frontal lobe (post inf part)

Receptive (sensory) dysphasia and affected area

Failure to understand the meaning of words

Superior temporal lobe (dominant lobe)

Which area is for Comprehension ?

Wernicke’s area

Which are is for expression ?

Broca’s area

Which hemisphere does dysphasia involve?

Left (bc of language function being to that hemisphere)

Dysphasia in left handed people

After a lesion in either hemisphere

Where is the lesion if there are movement and touch processing issues?

Cortex

Where is the lesion f there is apraxia, graphesthesia and two-point discrimination?

Parietal Lobe

Where is the lesion if there is receptive dysphasia and temporal lobe seizures?

Temporal lobe

Where is the lesion if there are vision problems and occipital seizures? (Homonymous hemianopia - loss of the same half of the visual field in both eyes)

Occipital lobe

Where is the lesion if the tumours press on the optic chiasm, and affect vision? Sign : bitemporal hemianopia (loss of peripheral vision in both eyes)

Pituitary region

Where is the lesion if there is damage of crania nerves and motor deficits on either side of the body?

Brainstem

Why are CN III and VI considered false localisers?

Because they do not cross therefore weakness is on the same side as the lesion

Cerebral signs and lesions

On the same side

Oculomotor cranial nerve palsy

Deviated eyes (down and out), ptosis, anisocoria (unequal pupils) and the affected one is dilatated

Abducens cranial nerve palsy

eye cannot be abducted (turned inwards)