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Questions and Answers
What is the classic presenting symptom of subarachnoid hemorrhage (SAH)?
What is the classic presenting symptom of subarachnoid hemorrhage (SAH)?
Which grading system is used to classify the severity of subarachnoid hemorrhage?
Which grading system is used to classify the severity of subarachnoid hemorrhage?
What percentage of patients with subarachnoid hemorrhage may experience a warning headache prior to the event?
What percentage of patients with subarachnoid hemorrhage may experience a warning headache prior to the event?
Which of the following is considered the strongest risk factor for subarachnoid hemorrhage?
Which of the following is considered the strongest risk factor for subarachnoid hemorrhage?
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In the context of epidural hematomas, what typically leads to the risk of bleeding?
In the context of epidural hematomas, what typically leads to the risk of bleeding?
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What kind of headache is often associated with subarachnoid hemorrhage and reaches maximum intensity within seconds?
What kind of headache is often associated with subarachnoid hemorrhage and reaches maximum intensity within seconds?
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Which of the following is NOT a risk factor for subarachnoid hemorrhage?
Which of the following is NOT a risk factor for subarachnoid hemorrhage?
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What is the term used for a small bleed that may precede a larger subarachnoid hemorrhage?
What is the term used for a small bleed that may precede a larger subarachnoid hemorrhage?
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What is the main danger of intracranial hemorrhage?
What is the main danger of intracranial hemorrhage?
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Which of the following is not a type of intracranial hemorrhage?
Which of the following is not a type of intracranial hemorrhage?
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Which of the following symptoms is NOT commonly associated with intracranial hemorrhage?
Which of the following symptoms is NOT commonly associated with intracranial hemorrhage?
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What is the difference between intracranial hemorrhage and intracerebral hemorrhage?
What is the difference between intracranial hemorrhage and intracerebral hemorrhage?
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What demographic is at higher risk of devastating intracranial bleeding from minor trauma?
What demographic is at higher risk of devastating intracranial bleeding from minor trauma?
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When managing a patient with a deteriorating level of consciousness, which step should be prioritized?
When managing a patient with a deteriorating level of consciousness, which step should be prioritized?
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Which imaging technique is vital in identifying types of intracranial hemorrhage?
Which imaging technique is vital in identifying types of intracranial hemorrhage?
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What indicates a possible subarachnoid hemorrhage when interpreting lumbar puncture results?
What indicates a possible subarachnoid hemorrhage when interpreting lumbar puncture results?
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What appearance does subdural hematoma typically have on imaging?
What appearance does subdural hematoma typically have on imaging?
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Why might intracranial bleeding be easily missed during the initial phase?
Why might intracranial bleeding be easily missed during the initial phase?
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What change occurs to the appearance of blood on CT after about two weeks?
What change occurs to the appearance of blood on CT after about two weeks?
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What is a potential radiologic sign of increased intracranial pressure?
What is a potential radiologic sign of increased intracranial pressure?
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What is the recommended action if a CT scan is normal within the first 6 hours after SAH symptoms begin?
What is the recommended action if a CT scan is normal within the first 6 hours after SAH symptoms begin?
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What is the typical sensitivity range of CT scans for detecting SAH within the first 6 hours?
What is the typical sensitivity range of CT scans for detecting SAH within the first 6 hours?
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What might indicate the presence of subarachnoid hemorrhage on a CT scan?
What might indicate the presence of subarachnoid hemorrhage on a CT scan?
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How can the experience of the reader affect the sensitivity of a CT scan?
How can the experience of the reader affect the sensitivity of a CT scan?
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What should be prioritized when assessing a patient with potential intracranial hemorrhage?
What should be prioritized when assessing a patient with potential intracranial hemorrhage?
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What does Cushing’s triad indicate?
What does Cushing’s triad indicate?
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Which of the following is NOT a feature of Cushing’s triad?
Which of the following is NOT a feature of Cushing’s triad?
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What is the primary diagnostic tool for identifying intracranial hemorrhage?
What is the primary diagnostic tool for identifying intracranial hemorrhage?
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What occurs in the subacute phase of intracranial hemorrhage?
What occurs in the subacute phase of intracranial hemorrhage?
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What should be monitored during the initial assessment of a patient with a suspected intracranial hemorrhage?
What should be monitored during the initial assessment of a patient with a suspected intracranial hemorrhage?
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What is a neurological exam's role prior to intubation?
What is a neurological exam's role prior to intubation?
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Which sign indicates imminent herniation in a patient with intracranial hemorrhage?
Which sign indicates imminent herniation in a patient with intracranial hemorrhage?
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What should be monitored or managed to control intracranial pressure (ICP)?
What should be monitored or managed to control intracranial pressure (ICP)?
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Which patient situations would make the application of certain rules for trauma inappropriate?
Which patient situations would make the application of certain rules for trauma inappropriate?
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Which of the following is NOT a tenet to apply in managing patients with intracranial hemorrhage?
Which of the following is NOT a tenet to apply in managing patients with intracranial hemorrhage?
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What is a dangerous mechanism of injury that indicates a higher risk for intracranial hemorrhage?
What is a dangerous mechanism of injury that indicates a higher risk for intracranial hemorrhage?
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What is an appropriate course of action if signs of rapidly rising ICP are observed?
What is an appropriate course of action if signs of rapidly rising ICP are observed?
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What is crucial for patients with intracranial hemorrhage before hospital discharge?
What is crucial for patients with intracranial hemorrhage before hospital discharge?
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What should be aggressively treated alongside intracranial hemorrhage management?
What should be aggressively treated alongside intracranial hemorrhage management?
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When should the closure of anticoagulation treatment be considered in patients with intracranial hemorrhage?
When should the closure of anticoagulation treatment be considered in patients with intracranial hemorrhage?
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Study Notes
Introduction
- Intracranial hemorrhage (ICH) is a life-threatening emergency, where bleeding within the skull increases intracranial pressure, potentially damaging the brain and leading to permanent neurological deficits or death.
Four Categories of ICH
- ICH is categorized into four types: epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage.
- Intracranial hemorrhage refers to any bleeding within the skull.
- Intracerebral hemorrhage specifically refers to bleeding within the brain parenchyma.
- Common presenting symptoms include headache, nausea, vomiting, confusion, somnolence, or seizure.
- Patients can present with a wide spectrum of symptoms, ranging from alert and conversant to moribund.
- Minor head trauma can lead to devastating intracranial bleeding, especially in elderly, alcoholic, or anticoagulated patients.
Subarachnoid Hemorrhage (SAH)
- The classic symptom of SAH is an acute onset "thunderclap" headache reaching maximum intensity within seconds, often accompanied by loss of consciousness, vomiting, neck stiffness, or seizure.
- The headache is often located at the back of the head (occipital).
- Sentinel headache is a warning headache that precedes a larger, catastrophic bleed.
- Hunt and Hess Grading System classifies SAH severity based on clinical presentation.
- Risk factors for SAH include: recent exertion, hypertension, excessive alcohol consumption, sympathomimetic use, cigarette smoking, and family history.
- Most SAH is caused by the rupture of saccular aneurysms.
Epidural Hematomas (EDH)
- EDH is the accumulation of blood between the skull and the dura, usually occurring after significant blunt head trauma.
- Fractures of the temporal bone can disrupt the middle meningeal artery, leading to high-pressure bleeding within the cranial vault.
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Initial actions and primary survey:
- ABCD's: Airway, breathing, circulation, and disability.
- Neuroprotective rapid-sequence intubation protocol is preferred for intubation.
- Pre-intubation neurological exam should document Glasgow Coma Score (GCS), pupillary size and reactivity, and motor strength.
- Cushing's triad (hypertension, bradycardia, abnormal respiratory patterns) is a sign of rapidly increasing intracranial pressure and imminent brain herniation.
- Other herniation signs include lack of pupillary reaction and pupillary asymmetry.
Diagnostic Testing
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CT scan: The mainstay of diagnosis in ICH.
- Acute bleeding appears hyperdense (whiter) on CT.
- Subacute phase (days 3-14) blood appears isodense (same shade of grey) to brain parenchyma.
- Chronic phase (after two weeks) blood appears hypodense (darker) relative to the brain.
- Increased intracranial pressure can be identified on CT by midline shift, ventricular compression, obliteration of sulci, and blurring of the grey-white junction.
Treatment
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Medical treatment:
- Assess and reassess ABCD's.
- Discontinue or reverse anticoagulation.
- Prevent hypotension and hypoxemia.
- Control ICP.
- Prevent seizure: prophylaxis may be necessary.
- Treat fever and infection aggressively.
- Control blood glucose (target 140-185 mg/dL).
- ICP control strategies: monitoring/lowering blood pressure, head elevation (30 degrees), sedation and analgesia, mannitol, mild hyperventilation.
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Surgical treatment:
- Timely neurosurgical consultation is crucial for patients with intracranial hemorrhage.
Disposition
- Most patients with ICH require close observation in an intensive care unit or neurosurgical ward.
- Physiotherapy and occupational therapy are often required before discharge.
Pearls and Pitfalls
- Many patients present with headache, but only a small percentage have a serious intracranial hemorrhage.
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Description
Explore the critical topic of intracranial hemorrhage (ICH), a life-threatening emergency involving bleeding within the skull. This quiz covers the four categories of ICH, including symptoms, causes, and specific conditions like subarachnoid hemorrhage. Prepare to deepen your understanding of this medical emergency.
