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neuro ICU > AHA 2012 aSAH guidlines > Flashcards

AHA 2012 aSAH guidlines Flashcards

1
Q

Time frame in which the risk of rebleeding is maximal?

A

the first 2-12 hours

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2
Q

Which has the worst outcome: early or late rebleeding?

A

early rebleeding is associated with worse outcome than later rebleeding

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3
Q

Factors associated with aneursym rebleeding? (6)

A
  1. longer time to aneurysm treatment
  2. worse neurological status on admission
  3. initial loss of consciousness
  4. previous sentinel headaches
  5. larger aneurysm size
  6. systolic BP > 160
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4
Q

Recommendations for BP control to prevent rebleeding after aSAH? (goal BP and what agents?)

A

The management of BP to reduce risk of rebleeding has not been established. Decrease to < 160 SBP (class IIa). Nicardipine and Clevidipine may give smoother control than labetalol and sodium nitroprusside

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5
Q

If there is a delay in obliteration of aneurysm and increased risk of rebleeding, what can be done in the interim (2)?

A

aminocaproic acid/tranexamic acid (decreased risk of bleed but 3mo outcome was unaffected, increased risk of DVT). NOT approved by FDA for prevention of aneursym rebleeding

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6
Q

Incidence of aSAH in the US?

A

9.7/100,000

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7
Q

What percent of patients with aSAH die before hospital admission?

A

12-15% of cases

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8
Q

Average of onset?

A

> /= 50 years of age

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9
Q

incidence in females vs males?

A

incidence in women is 1.24 times higher than in men

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10
Q

incidence by race?

A

Black and Hispanics have a higher incidence of aSAH than white Americans

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11
Q

behavioral risk factors for aSAH? (5)

A
  1. HTN
  2. smoker
  3. alcohol abuse
  4. use of sympathomimetic drugs (cocaine)
  5. diet/body mass index
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12
Q

other non-modifable risk factors? (6)

A
  1. female
  2. unruptured cerebral aneurysm
  3. hx of previous aSAH
  4. hx of familial aneurysms
  5. family history of aSAH
  6. certain genetic syndromes (ie ADPKD, type 4 Ehlers-Danlos, etc)
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13
Q

What factors increase risk of aneurysm rupture? (3)

A
  1. Location
    - anterior circulation aneursyms rupture more in pts < 55 yrs
    - PCOMM aneurysms rupture more in men
    - basilar artery aneurysm rupture is associated with alcohol use
  2. size > 7mm (smaller in pts with combination HTN and smoking)
  3. significant life events (ie financial or legal problems)
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14
Q

Does preganancy/delivery increase risk of rupture?

A

no

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15
Q

How can a statin and CCB be helpful in decreasing risk?

A

may retard aneurysm formation through inhibition of NF-kB and other pathways

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16
Q

What morphology characteristics are associated with rupture? (2)

A
  1. bottleneck shape

2. ratio of size of aneurysm to parent vessel

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17
Q

Who should be screened for aneurysms? (2)

A

familial aneurysm or 1st degree relative with aSAH

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18
Q

What are the results of the CARAT trial? (2)

A

Cerebral Aneurysm Rerupture After Txt. recurrent aSAH was (1) predicted by incomplete obliteration of the aneurysm (2) occurred a median of 3 days after treatment but rarely after 1 year

19
Q

What is the median mortality rate for aSAH in the US?

A

32%

20
Q

Mortality rate: women vs men? By race?

A

Higher mortality in women than in men. Higher mortality in blacks, American Indians, and Asians compared to whites.

21
Q

Relationship between cognitive function and aSAH?

A

Cognitive fxn tends to improve over the first year, global cognitive impairment is present in ~20% of aSAH patients and is associated with poorer functional recovery and lower quality of life.

22
Q

What is the strongest prognostic indicator for aSAH?

A

The severity of clinical presentation in the strongest prognostic indicator in aSAH?

23
Q

What is the classic presentation of aSAH ? (what % of patients present with classic sx?) Other typical associated sx? (5)

A

worst headache of my life which 80% of pts p/w. Other classic sx include: N/V, stiff neck, photophobia, brief LOC, FND

24
Q

% of patient that present with sentinel HA?

A

10-43% of patients

25
Q

Sentinel headaches increase the risk of rebleeding by__?

A

10 fold

26
Q

What is the most common diagnostic error in aSAH?

A

failure to obtain a non-contrast head CT

27
Q

What is a sentinel bleed?

A

minor hemorrhage before a major rupture

28
Q

Time course of when sentinel bleeds become over aSAH?

A

2-8 weeks

29
Q

Common symptoms of a sentinel bleed?

A

headache, N/V. Meningismus is uncommon

30
Q

What is the incidence of seizures in SAH?

A

Seizures may occur in up to 20% of patients after aSAH

31
Q

seizures in aSAH are highly associated with?

A

more commonly in aSAH associated with intracerebral hemorrhage, HTN, MCA, and ACOM aneurysms

32
Q

CT is 100% sensitive for how many days?

A

The sensitivity of CT in the first 3 days after aSAH remains very high (close to 100%) after which it decreases. After 5-7 days, the rate of negative CT increases sharply, and LP is needed to show xanthochromia.

33
Q

CTA may miss aneurysms of what size?

A

< 3mm

34
Q

What is the utility of getting a CTA in the diagnosis of aSAH? What if the CTA is inconclusive?

A

If an aneurysm is detected by CTA, thus study may help guide the decision for type of aneurysm repair. If inconclusive, DSA is recommended.

35
Q

Utility of DSA with 3D rotational angiography?(2)

A

Indicated for 1. detection of aneurysm in pts with aSAH (if not diagnosed by noninvasive angiogram) and 2. for planning txt (coiling vs expediting microsurgery)

36
Q

Which trial compared clipping vs coiling?

A

ISAT, randomized 2143 of 9559 screened patients with aSAH across 42 neurosurgical centers.

37
Q

For clipping vs coiling, which had:

(1) increased death/disability
(2) increased rate of complications
(3) increased rate of late rebleeding
(4) increased percent of complete obliteration?

A

Clipping vs coiling:

(1) death/disability: CLIPPING - 31%/22%; coiling - 24%/16%
(2) complications: CLIPPING - 19%; coiling - 8%
(3) late rebleeding: Clipping - 0.9%, COILING - 2.9%
(4) complete obliteration: CLIPPING - 81%; coiling -15%

38
Q

the rate of incomplete occlusion and subsequent aneurysm recurrence depends on what 2 factors?

A

depends critically on neck diameter and dome size

39
Q

In what type of aneurysm would flow diverting stent be preferred?

A

low-porosity flow-diverting stents is preferred in patients with a dissecting aneurysm in whom vessel sacrifice is not an option and microsurgical solutions carry higher risk

40
Q

What are long term concerns of endovascular coil treatment?

A

short term efficacy of endovascular coil obliteration is well established, but long term durability remains a concern

41
Q

Would EVT or microsurgery be preferred in the following situations:

  1. large > 50ml intraparanechymal hematoma
  2. MCA aneurysms
  3. elderly (>70 yo)
  4. poor grade aSAH (per WFNS score)
  5. basilar apex/posterior circulation aneursyms
A
  1. large > 50ml intraparanechymal hematoma = microsurgery (unless patient has vasospasm in which case EVT is preferred)
  2. MCA aneurysms = microsurgery
  3. elderly (>70 yo) = EVT (long term durability is less important
  4. poor grade aSAH (per WFNS score) - EVT
  5. basilar apex/posterior circulation aneursyms - coiling
42
Q

In patients with coiling of basilar artery aneurysm who have near-complete occlusion, ___% experienced recannalization

A

47%

43
Q

Next step in management of patients who undergo coiling of posterior circulation aneurysms?

A

sequential DSA, especially those who do not exhibit complete occlusion on immediate follow-up angiography

neuro ICU (1 decks)

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