Perfusion Disturbances of the Brain

Brain Hemorrhage

Sudden Headache

Checklist:

Does the patient suffer from chronic headache attacks or is this a new type of headache? Is there a history of medication with headache as potential side effect or could the patient be intoxicated? Did the headache occur under physical stress or exertion?

Does the patient suffer from arterial hypertension? Is the headache accompanied by other neurological symptoms or loss of consciousness?

I The Case of Will Klington

Out of the Blue

Will Klington (37) is brought to the emergency unit unconscious. It is late at night. His escorts report that Will started to complain about a sudden, severe headache completely "out of the blue," then vomited and lost consciousness a few minutes later. The colleague on duty has immediately transferred the patient to CT, where Giufeng and Greg are working together this evening. The CT shows an impressive finding (Fig. 11.2). Gregory leaves Giufeng exactly one minute for her diagnosis and runs out of the room.

Cluster Headache Mri Image
Fig. 11.2 Here you see the relevant CT image of Will Klington's head.

• What is Your Diagnosis?

Migraine, cluster-headache: Migraine and cluster headache are clinical diagnoses and are not associated with any positive findings on imaging modalities. CT and MRI usually do not show any abnormality.

Subarachnoid hemorrhage (SAH): This type of hemorrhage is most often caused by the rupture of a preexisting aneurysm of the circle of Willis but can also occur in trauma. It is diagnosed with great accuracy by simple noncontrast CT (Fig. 11.3a) and may be missed in standard MRI. SAH

I Subarachnoid Hemorrhage (SAH) and Its Consequences

Left Lateral Ventricle Hemmorhage

Fig. 11.3a The fine, dense lines in the sylvian fissure (arrows) correspond to blood in the subarachnoid space. A small amount of blood is also seen in the posterior horn of the left lateral ventricle: The acute hemorrhage must have worked its way through the cerebral parenchyma (visible on other sections) and broken through into the ventricle. The ventricles are already distended because blood clots almost always find their way into the narrow aqueduct and tend to obstruct it. A ventriculostomy needs to be

Fig. 11.3a The fine, dense lines in the sylvian fissure (arrows) correspond to blood in the subarachnoid space. A small amount of blood is also seen in the posterior horn of the left lateral ventricle: The acute hemorrhage must have worked its way through the cerebral parenchyma (visible on other sections) and broken through into the ventricle. The ventricles are already distended because blood clots almost always find their way into the narrow aqueduct and tend to obstruct it. A ventriculostomy needs to be inserted. b After pronounced SAH, normal-pressure hydrocephalus may develop. In this patient, two weeks after an SAH the temporal horns are distended and the fourth ventricle also appears enlarged. Obstruction of the aqueduct alone would not explain this combination of findings. CSF resorption over the cerebral convexities, however, is severely compromised by the SAH sequel. Normal-pressure hydrocephalus is treated by spinal tap or insertion of a drain to relieve the pressure.

I Embolization of an Aneurysm

I Embolization of an Aneurysm

Temporal Horns Nph

Fig. 11.4a Subtraction angiography of the posterior cranial circulation in this patient demonstrates a pedunculated aneurysm (arrow) originating from the tip of the basilar artery close to the origin of the posterior cerebral arteries. b A number of small coils are deposited in the aneurysm through a very fine catheter under fluoroscopic guidance. c The postinterventional angiographic image shows a normalized vascular pattern.

Fig. 11.4a Subtraction angiography of the posterior cranial circulation in this patient demonstrates a pedunculated aneurysm (arrow) originating from the tip of the basilar artery close to the origin of the posterior cerebral arteries. b A number of small coils are deposited in the aneurysm through a very fine catheter under fluoroscopic guidance. c The postinterventional angiographic image shows a normalized vascular pattern.

without trauma should always prompt angiography to search for an aneurysm (Fig. 11.4a), because it may continue to bleed or re-bleed with lethal consequences. A considerable number of aneurysms can be taken care of right away by interventional neuroradiology therapy (Fig. 11.4b, c). In all other cases it is the neurosurgeon's turn. Other reasons for SAH are venous hemorrhages or bleeding arteriovenous malformations (AVM).

One major complication of SAH in an aneurysmal rupture is the breakthrough of the hemorrhage into the brain parenchyma and further into the ventricular system (see below). If the SAH is so pronounced that it obliterates a major part of the total subarachnoid space of the brain and thus hinders the resorption of the CSF that normally takes place there, an aresorptive hydrocephalus may develop (Fig. 11.3b).

Intracranial hemorrhage: Spontaneous intracranial hemorrhage may occur as a sequel of long-standing poorly controlled arterial hypertension, particularly in the basal ganglia. If rupture into the ventricles occurs, ventricular tamponade and obstruction of the aqueduct may ensue, which leads to hydrocephalus. Neurosurgical ventricu-lostomy must then be performed immediately. Vascular malformations, tumors, metastases, infarction, vasculitis, and coagulopathies (including iatrogenic warfarin!) can also cause hemorrhage into the brain parenchyma. Diagnosis of an intracranial bleed is made with noncontrast CT (Fig. 11.5). MRI serves to establish the etiology of the bleed at a later time.

• Diagnosis: Giufeng quickly realizes why Gregory has left right away. He is a passionate neuroangiographer and interventionalist and has already made sure that the angiography suite and the staff there are prepared

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