Summary of various causes of intracranial pressure required for medical school examinations. Conditions include various causes of intracranial haemorrhage and idiopathic intracranial hypertension.
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Description
Subarachnoid haemorrhages (SAH) encompasses spontaneous bleeding into the subarachnoid space, often
catastrophic. Affects 9/100,000 patients/year, typically between the ages of 35-65 YO. Subarachnoid vessels are
loosely supported so are therefore more easily broken in trauma.
Presentation Management
- Key: Thunderclap headache (Sudden pain Relief) - Initial Management
- Prodrome: ‘Sentinel’ headache is felt in 6 % o Refer: Emergency neurosurgery referral
- Kernig’s Test: Neck stiffness >6 hrs post-SAH o Monitor CNS: BP; Pupillary response; GCS
- Test: Pain when knee is extended on full hip flexion o Maintain Perfusion: Fluids; SBP <160 mmHg
- Terson’s Syn: Retinal; Subhyaloid; Vitreous bleeds - Neurosurgical Management
- Stroke: Stroke signs seen in aneurysm o Coil: Endovascular coiling via femoral a.
- ↑ ICP: Cushing’s triad in intracerebral haematoma o Clip: Requires craniotomy
Causes o Balloon: Novel; Diverts flow away from site
- Trauma: Commonest cause overall o Prophylaxis: Nimodipine 3 wks; ↓ Vasospasm
- Other: Aneurysm (2nd); AVM (3rd) Complications
- APCKD: 5-7 % of adults (↑ risk 5x) - Common: Re-bleeding (10-20 %)
- Berry Aneurysm: 85 %; APCKD; Ehler’s Danlos syn. - Vasospasm: Cerebral ischaemia; Mean 7-14 d
- Common Junctions: ICA-PCA; ACA-ACoA; MCA Bifur. - SIADH: Hyponatraemia Hydrocephalus
- NB: 15 % of aneurysms are multiple areas Prognosis
- AVM: 15 %; Abnormal tangles disrupts blood flow - Px: See figure below for scoring
Investigations
- Fundoscopy: Vitreous bleed in Terson’s syndrome
- Head CT: Detects >95 % within first 24 hr
- Consider LP: Xanthochromic CSF (>12 hr post-SAH)
- ECG: Note that ST elevation may be seen
, Grading and Prognosis of SAH
Grade Signs Mortality (%)
I None 0
II Neck stiffness and cranial nerve palsies 11
III Drowsiness 37
IV Drowsy with hemiplagia 71
V Prolonged coma 100
Common Aneurysm Locations
s
Location Prevalence
Anterior Communicating Artery Aneurysm 40 %
Posterior Communicating Artery Aneurysm 24 %
Middle Cerebral Artery Aneurysm 20 %
Basilar Tip Aneurysm 8%
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