Makindo Medical Notes

Related Subjects: |Subarachnoid Haemorrhage |Perimesencephalic Subarachnoid haemorrhage |Haemorrhagic stroke |Cerebellar Haemorrhage |Putaminal Haemorrhage |Thalamic Haemorrhage |ICH Classification and Severity Scores |Brain Herniation syndromes |Epidural Haematoma

Potential for excellent recovery with timely clot evacuation and urgent neurosurgical intervention.

About

• Can cause acute, usually persistent vertigo with additional neurological symptoms.

Location and Prognosis

• Midline lesions: Higher risk due to potential damage to deep cerebellar nuclei.
• Hemispheric lesions: Better prognosis, especially with more lateral bleeds.

Causes

• Hypertensive rupture of small penetrating vessels.
• Amyloid angiopathy, substance use (e.g., cocaine), AV malformations.
• Hemorrhagic tumors, anticoagulant use, coagulopathies.
• Spinal surgery complications, spontaneous intracranial hypotension.

Clinical Presentation

• Sudden onset of nausea, vertigo, headache, vomiting.
• Ipsilateral cerebellar signs, possible cranial nerve VI and VII involvement.
• Truncal ataxia, difficulty walking, often unable to ambulate independently.
• Signs of brainstem compression in severe cases (coma, pupillary abnormalities).
• Neck stiffness, loss of corneal reflexes, pinpoint pupils, Cheyne-Stokes breathing in severe cases.

Poor Prognostic Indicators and Complications

• Hematoma >3 cm.
• Significant brainstem compression, leading to decreased brainstem perfusion.
• Acute hydrocephalus (typically obstructive, often at the fourth ventricle).
• Midline lesions and intraventricular extension of bleeding.
• Low Glasgow Coma Scale (GCS) on presentation.

Differential Diagnosis

• Brainstem stroke.
• Labyrinthitis.
• Intoxication (often misinterpreted as alcohol intoxication in early presentation).
• Drug toxicity, especially anticonvulsants.

Investigations

• FBC, coagulation profile (including INR if on warfarin), U&E, LFTs.
• ECG and chest X-ray as indicated.
• Urgent CT head scan for diagnosis, assessing bleed size, hydrocephalus, brainstem shift, and intraventricular blood.
• MRI may be used in stable patients, particularly if a structural lesion is suspected.

Management

• ABC and ICU/ITU consideration: For rapid deterioration or comatose patients as a bridge to surgery. Neurosurgical evaluation is critical in cases with brainstem compression or hydrocephalus.
• Surgical Intervention:
  • Patients with GCS <14, clot >3 cm, and/or hydrocephalus may benefit from suboccipital craniotomy with clot evacuation.
  • For patients with GCS 14-15, clot <3 cm, and no hydrocephalus, conservative management is possible with neurosurgical monitoring.
  • Consider Mannitol (1 g/kg) acutely for high intracranial pressure as a bridge to surgery.
• Manage Coagulopathies: Correct any anticoagulant effects, e.g., with Octaplex/Beriplex and IV Vitamin K if on warfarin. Control hypertension carefully and consult neurosurgery.
• Stroke Unit Admission: For monitoring and rehabilitation in patients not requiring immediate surgery.
• Escalation for Deterioration: Monitor for any neurological changes. End-of-life care may be appropriate in cases with severe brainstem involvement or coma.
• Multidisciplinary Stroke Rehabilitation: Essential for long-term recovery; patients may achieve significant improvement with time and rehabilitation.