• CONSCIOUSNESS - state of awareness of self + surr

1. Intact cerebral hemispheres
2. Intact reticular activating system BS - midbrain, hypothalamus, thalamus
3. GCS - see WCS 2

• COMA - no speech/ eye opening/ motor response

1. Intracranial - trauma, vascular, infective, neoplastic
2. Extra-cranial - metabolic, drugs & toxin, vascular occlusion, endocrine, respiratory insufficiency, cardiac insufficiency, psychiatric

• History

• P/E

Causes

• Tension headache - 95%
• Migraine - one-sided, preceded by aura/ vomiting, pulsatile
• Raised ICP

• Intracranial - venous sinuses, cortical veins, basal arteries, dura mater
• Extracranial - scalp vessels & muscles, orbital content, mucous membranes, external & middle ear, teeth & gum

• Ischaemic (HK 70%, West 85%)

1. vessel occlusion: carotid, IC BV
2. embolism: atrial fib, arrhythmia
3. arteritis
4. blood disorder

• Haemorrhagic (HK 30%, West 15%)

1. intracerebral haemorrhage
2. subarachnoid haemorrhage

1. Prevention - becoming more imp
2. Acute treatment for brain attack
3. Rehabilitation

• Concept of Brain Attack
• Therapeutic window of 3-6 hours (lyse clot, recanalise BV, reperfuse brain)
• Stroke thrombolysis - eg. TPA

• Open neck, remove atheroma, enlarge conduit
• Justified if occlusion > 70%
• Risk: peri-operative stroke (b/c clamp BV to brain)

• hydrocephalus: cerebellum in post fossa (all post fossa path require drainage of CSF)
• brain stem compression
• surgical options

1. ventriculostomy
2. suboccipital craniectomy, infarctectomy (remove infarct)
3. More aggressive Tx b/c if lesion, Pt trouble walking/ balancing (not as severe as cerebral hemispheres)

• Hypertension - 40%
• Vascular: AVM, Cavernoma, Aneurysm
• Haemorrhagic infarct
• Amyloid angiopathy
• Tumour
• Bleeding tendency
• Sympathomimetic abuse
• Venous sinus thrombosis
• Moya Moya

• Aneurysm 75%
• AVM 5%
• tumour, bleeding tendency 5%
• idiopathic 15% (even after angiogram, MRI) - Note: most idiopathic are very small aneurysms + AVM that cannot be seen in Ix

1. Haemodynamic stress on arterial bifurcation
2. congenital weakness of arterial wall
3. abnormal circle of Willis

• incidence of cerebral aneurysm

1. incidence increase with age
2. 2-5% of adult population
3. mean age of SAH 50

• Presentation

1. rupture
2. subarachnoid haemorrhage
3. mass effect
4. cranial nerve palsy
5. oculomotor (PCoA, basilar)
6. optic (ophthalmic artery)

• sudden onset of severe headache ("most severe headache ever experienced")
• LOC
• P/E neck rigidity
• Fundi - subhyaloid ocular haemorrhage

1. Delayed cerebral ischaemia
2. starts on Day 4
3. maximum on Day 7-Day 10
4. resolves within 2-3 week
5. cause: blood in CSF, SAH

• Hydrocephalus

Aneursmal SAH

CT scan

95% +ve 5% -ve

v sug LP RBC xanthochromia

Clinical grading SAH

Grade 1,2,3 Grade 4,5

4 vessels angiogram conservative

clipping ICH

endovascular coiling

Clinical grading:

1 = very good condition

5 = moribund

"3 bottle test" to distinguish between epidural vein puncture (traumatic tap 1>2>3) and subarachnoid haemorrhage (1=2=3)

GCS Motor deficit

Grade 1 15 -

Grade 2 13-14 -

Grade 3 13-14 +

Grade 4 7-12 +/-

Grade 5 3-6 +/-

• Nimodipine (Ca++-channel blocker)

• Antifibrinolytics

• Early clipping of aneurysm, nimodipine
• Baseline haemodilution Hct 30-34
• Hypertensive Px, SBP to 200 mmHg or deficits resolve
• Endovascular intervention, Angioplasty, Intra-arterial papaverine

• Hydrocephalus
• obstructing CSF flow in subarachnoid space
• CSF drainage provokes rebleeding

• Microsurgical clipping - clip neck (classical Tx)
• Endovascular coiling - "regrowth of aneurysm after coiling - blood pushes out coil) - eg. GDC coiling of aneurysm - Guglielmi Detachable Coils (coil = embolic material)

1. Rupture
2. "Steal phenomenon" - ischaemic around AVM
3. Epilepsy - 50%

• abnormally developed arteries and vein without intervening capillary
• AV shunting, Venous varix is common
• aneurysm on feeding artery 15%
• Presentation

• Each bleed

1. 10% mortality; 30-50% morbidity
2. Small AVMs bleed > large AVMs
3. Risk of bleeding 2-4% per year

Risk of bleeding 3% per year

Expected years of remaining life

Risk of bleeding (at least once) = 1- [annual risk of not bleeding]

Age 25 at diagnosis - expected to live up to 80

55

Risk of bleeding = 1- (0.97) = 1 - 0.18 = 82% (lifetime risk)

• surgical excision, embolisation, radiosurgery

Points

Size <3 cm 1

3-6 cm 2

>6 cm 3

Eloquence area non-eloquent 0

Venous drainage superficial only 0

Deficit - + ++

Grade 1 100%

Grade 2 95% 5%

Grade 3 84% 12% 4%

Grade 4 73% 20% 7%

Grade 5 69% 19% 12%

Embolisation of AVM - catheter injected into cerebral BV, embolic material injected

• Death 1-2%
• Severe deficit 1-5%
• Minor deficit 9%
• Transient deficit 11%
• Haemorrhage 10%
• Seizure 3%

• 4th ventricular obstruction, BS compression
• brain stem compression
• surg: ventricular drainage, suboccipital craniectomy, clot evacuation

Lobar Haemorrhage - haematoma on surface of brain, usually struc cause (eg. AVM)

• Operative intervention provide diagnosis
• Need to exclude vascular abnormality
• Surgery better than medical Tx

Ganglionic Haemorrhage - occurs at BG, aka internal capsule haemorrhage, deep tissue, caused by HT

Thalamic Haemorrhage - spill into ventricle - hydrocephalus

• conservative treatment
• CSF diversion for hydrocephalus