AHA 2012 aSAH guidlines Flashcards
Time frame in which the risk of rebleeding is maximal?
the first 2-12 hours
Which has the worst outcome: early or late rebleeding?
early rebleeding is associated with worse outcome than later rebleeding
Factors associated with aneursym rebleeding? (6)
- longer time to aneurysm treatment
- worse neurological status on admission
- initial loss of consciousness
- previous sentinel headaches
- larger aneurysm size
- systolic BP > 160
Recommendations for BP control to prevent rebleeding after aSAH? (goal BP and what agents?)
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
If there is a delay in obliteration of aneurysm and increased risk of rebleeding, what can be done in the interim (2)?
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
Incidence of aSAH in the US?
9.7/100,000
What percent of patients with aSAH die before hospital admission?
12-15% of cases
Average of onset?
> /= 50 years of age
incidence in females vs males?
incidence in women is 1.24 times higher than in men
incidence by race?
Black and Hispanics have a higher incidence of aSAH than white Americans
behavioral risk factors for aSAH? (5)
- HTN
- smoker
- alcohol abuse
- use of sympathomimetic drugs (cocaine)
- diet/body mass index
other non-modifable risk factors? (6)
- female
- unruptured cerebral aneurysm
- hx of previous aSAH
- hx of familial aneurysms
- family history of aSAH
- certain genetic syndromes (ie ADPKD, type 4 Ehlers-Danlos, etc)
What factors increase risk of aneurysm rupture? (3)
- 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 - size > 7mm (smaller in pts with combination HTN and smoking)
- significant life events (ie financial or legal problems)
Does preganancy/delivery increase risk of rupture?
no
How can a statin and CCB be helpful in decreasing risk?
may retard aneurysm formation through inhibition of NF-kB and other pathways
What morphology characteristics are associated with rupture? (2)
- bottleneck shape
2. ratio of size of aneurysm to parent vessel
Who should be screened for aneurysms? (2)
familial aneurysm or 1st degree relative with aSAH
What are the results of the CARAT trial? (2)
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
What is the median mortality rate for aSAH in the US?
32%
Mortality rate: women vs men? By race?
Higher mortality in women than in men. Higher mortality in blacks, American Indians, and Asians compared to whites.
Relationship between cognitive function and aSAH?
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.
What is the strongest prognostic indicator for aSAH?
The severity of clinical presentation in the strongest prognostic indicator in aSAH?
What is the classic presentation of aSAH ? (what % of patients present with classic sx?) Other typical associated sx? (5)
worst headache of my life which 80% of pts p/w. Other classic sx include: N/V, stiff neck, photophobia, brief LOC, FND
% of patient that present with sentinel HA?
10-43% of patients
Sentinel headaches increase the risk of rebleeding by__?
10 fold
What is the most common diagnostic error in aSAH?
failure to obtain a non-contrast head CT
What is a sentinel bleed?
minor hemorrhage before a major rupture
Time course of when sentinel bleeds become over aSAH?
2-8 weeks
Common symptoms of a sentinel bleed?
headache, N/V. Meningismus is uncommon
What is the incidence of seizures in SAH?
Seizures may occur in up to 20% of patients after aSAH
seizures in aSAH are highly associated with?
more commonly in aSAH associated with intracerebral hemorrhage, HTN, MCA, and ACOM aneurysms
CT is 100% sensitive for how many days?
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.
CTA may miss aneurysms of what size?
< 3mm
What is the utility of getting a CTA in the diagnosis of aSAH? What if the CTA is inconclusive?
If an aneurysm is detected by CTA, thus study may help guide the decision for type of aneurysm repair. If inconclusive, DSA is recommended.
Utility of DSA with 3D rotational angiography?(2)
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)
Which trial compared clipping vs coiling?
ISAT, randomized 2143 of 9559 screened patients with aSAH across 42 neurosurgical centers.
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?
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%
the rate of incomplete occlusion and subsequent aneurysm recurrence depends on what 2 factors?
depends critically on neck diameter and dome size
In what type of aneurysm would flow diverting stent be preferred?
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
What are long term concerns of endovascular coil treatment?
short term efficacy of endovascular coil obliteration is well established, but long term durability remains a concern
Would EVT or microsurgery be preferred in the following situations:
- large > 50ml intraparanechymal hematoma
- MCA aneurysms
- elderly (>70 yo)
- poor grade aSAH (per WFNS score)
- basilar apex/posterior circulation aneursyms
- large > 50ml intraparanechymal hematoma = microsurgery (unless patient has vasospasm in which case EVT is preferred)
- MCA aneurysms = microsurgery
- elderly (>70 yo) = EVT (long term durability is less important
- poor grade aSAH (per WFNS score) - EVT
- basilar apex/posterior circulation aneursyms - coiling
In patients with coiling of basilar artery aneurysm who have near-complete occlusion, ___% experienced recannalization
47%
Next step in management of patients who undergo coiling of posterior circulation aneurysms?
sequential DSA, especially those who do not exhibit complete occlusion on immediate follow-up angiography
