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Vascular > Aneurysms and SAH > Flashcards

Aneurysms and SAH Flashcards

1
Q

Incidens of aSAH?

A

8/100.000

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2
Q

What is Terson syndrome?

A

A concurrent intraocular hemorrhage within the vitreous humor. 4-27% of aSAH

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3
Q

How often is subhyaloid hemorrhage that can be seen fundoscopically as abright red blood near the optic disc that obscures the underlying retinal vessels seen after aSAH?

A

11-33%!!

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4
Q

Median age SAH and mean age?

A

58yo, 50-55yo

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5
Q

Contributing factors for an intracranial aneurysm to rupture?

A
  • age over 60
  • posterior circulation a
  • size over 5mm
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6
Q

Risk factors for aneurysmal SAH

A
  • hypertension
    *cigarette smoking
  • previous aSAH?
  • alkohol
  • Sympathomimetic drugs
    *estrogen deficiency?
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7
Q

Causes of non-aneurysmal SAH?

A
  • perimesencephalic
  • Occult
  • Vascular malformations (AVM or dAVF)
  • Dissection
  • Cocain abuse
  • Cerebral amyloid angiopathy
  • Cerebral venous thrombosis
  • Sickle cell anemia
  • MoyaMoya
  • Cerebral vasculitis
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8
Q

What two counties have higher burden of aSAH?

A

Finland and Japan.

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9
Q

What is a dolichoectasic aneurysm?

A

elongated, tortuous, and sometimes dilated vessel segments

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10
Q

When should an LP be done in case of negative CT and high suspicion of SAH?

A

A lumbar puncture should ideally be performed 6 hours after the initial Head CT to detect the presence of xanthochromia.

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11
Q

How frequent is hcph after aSAH ?

A

about 25% up to 30%

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12
Q

How many% of aSAH pt have a radiographically vasospasm?

A

60%

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13
Q

How many patients have a clinical manifestation of vasospasm?

A

about 30%

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14
Q

What is TCD?

A

transcranial doppler

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15
Q

When is EVD indicated?

A

in patients with enlarged ventricles on CT or with WFNS scale score ≥3;

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16
Q

When is the highest risk of re-bleeding after aSAH?

A

The most significant risk of rebleeding and mortality is within the first 6 hours of the initial hemorrhage.

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17
Q

Riskfactors for rebleeding?

A

*Elevated systolic blood pressure,
*poor Hunt-Hess grades, *intracerebral or intraventricular hematomas,
*aneurysms > 10 mm in size,
*aneurysms in the posterior circulation

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18
Q

How many % of rebleedings occur within 3h and 6h (from aSAH)?

A

1/3 and 1/2

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19
Q

What is the mortality rate in rebleeding cases?

A

50-70%

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20
Q

What is the daily rebleeding risk after aSAH if not treated from 24h after ictus to day 13?

A

1.5% daily.

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21
Q

what is the yearly rebleeding risk after 6 mo from ictus?

A

3% per year

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22
Q

What is the yearly mortality rate 6 mo after aSAH?

A

2%/yr

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23
Q

What is the risk of rebleeding after securing the aneurysm?

A

1%

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24
Q

What antifibrinolytic drug should be given after aSAH?

A

Tranexamic acid, 1g immidiately and then 1g/6h in 72h or until treatment.

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25
Q

What are the two prefered substances for BP control after aSAH?

A
  • Labetalol
  • Hydralazine
26
Q

What is the only known vasospasm preventing drug?

A

Nimodipine. 60mg Q4h for 21 days. if hypotension is a problem, give 30mg q 2h.

27
Q

What is Clazosentan?

A

An endothelin antagonist found to have an effect on radiographic vasospasm. Under study for clincal benefit.

28
Q

Does statins have a role in SAH?

A

nope. But no problem either if taken since before.

29
Q

What is the accepted clinical parxis for starting VTE profylaxis after aSAH surgery?

A

24h-48h.

30
Q

What is WFNS used for?

A

It describes the clinical presentation of SAH patients and help predict recovery and response to treatment.

31
Q

How many percent of patients w SAH died before evaluation in hospital (published 2017)

A

18%

32
Q

What is neurogenic pulmonary edema?

A

p 1237

33
Q

what is neurogenic stunned myocardia?

A
34
Q

How many survivors have moderate to severe disability?

A

30%

35
Q

WHat are the two most predictive factors to outcome after aSAH?

A
  1. WFNS!
  2. age (70)
36
Q

What is the most common cause of SAH at all?

A

trauma

37
Q

What heredity is considered to be a riskfactor for aneurysm and aSAH?

A

more than 1 1st degree family member.

38
Q

What is the prevalence of aneurysms?

A

uncertain data. About 1-5% of the population.

39
Q

How much more common is an unruptured aneurysm in women compared to men?

A

1:3.

40
Q

What is the mortality rate fpr aSAH with IVH?

A

64%

41
Q

What type of visual defect occurs from compressive opthalmica aneurysm?

A

Nasal quadrantanopsia

42
Q

What aneurysms might cause chiasmal syndromes?

A
  • opthalmic
  • a-comm
  • basilar apex
43
Q

Which aneurysm locations may cause facial pain syndromes mimicing trigeminal neuralgia?

A
  • intracavernous
  • supraclinoid
44
Q

Prolonged time to surgery has been found to be correlated to worse outcome after aSAH. What is considered “prolonged time”?

A

3 days.

45
Q

ultraearly coiling of aSAH in pt w HH IV/V has been shown to correlate to improved clinical outcome. What was considered ultraearly?

A

within 24h.

46
Q

Data used for management of unruptured aneurysms usually rely on the following information (p1284Greenberg 9)
*annual risk of rupture (intermediate risk for 6-10mm )
*3mo mortality after aSAH
*Serious morbidity afteraSAH
*Surgical morbidity and mortality

What are the used figures?

A

1% annual risk
55% mortality after aSAH
15% Serious morbidity after aSAH
2% and 6% Surgical morbidity and mortality.

47
Q
A
48
Q

According to Greenberg 9, what are the important factors to take into decision of intervention or not for an UIA?

A
  • Size - under 7mm, 7-12mm or more than 12mm
  • Age - under or over 60yo
  • Anterior or posterior location.
    + risk factors for rupture: 1st line relative w ruptured a? symptomatic aneurysm? Enlargement or change in configuration?
    Obs! Pt that has had an aSAH shall be adviced intervention for UIA.
49
Q

Is the risk increased for UIAs if the patient has had a rupture from another aneurysm?

A

Yes.

50
Q

Several attempts to assess natural history of unruptured aneurysms have been done. Overall 7 major PATIENT factors and 3 major aneurysm factors seems to be important. Which?

A

A. Patient factors:
1. previous SAH from separate aneurysm
2. Multiple aneurysms
3. Age -conflicting evidence on rupture risk. Very strong evidence for outcome after SAH.
4. Medical conditions a. HT, b. smoking
5. Geographical location - USA/EUvsJapanvsFinland
6. Gender - can be discussed.
7. Family history - unclear. Perhaps correlated to 1st degree relative with aSAH.
B. Aneurysm characteristics
1. Size - Debate!
2. Location -Debate!
3. Morphology-more clear.

51
Q

Some rupture correlated factors are debated.
What is the debate for aneurysm size (regarding aneurysms 10mm or smaller)?

A

ISUIA study showed size under 10mm to have annual rupture risk of 0.05%.
A number of other studies show 1%/year!
“The small unruptured IC aneurysm verification study” showed annual rupture risk of aneurysm less than 5mm to be 0.5%.
Another study show that the most common size to rupture is less than 7mm (62%) and majority of those being aComA.

52
Q

What is the yearly rupture risk for 10-25mm aneurysms and giant aneurysms (more than 25mm)?

A

3-18% per year
and
8-50% per year.

53
Q

Morphology related to rupture is more clear. What are unpleasant signs?

A
  • precense of daughter sac
  • Bottleneck shape
  • Increased ratio aneurysm diameter vs parent vessel diameter.
54
Q

DIscussions are ongoing about risk of rupture related to location. WHat is the present “decision” on what is truth?

A

Some stuies show higher risk in posterior aneurysms. SOme show higher risk for aComA.
The present agreement is that posterior a have a higher risk.

55
Q

What is PHASES?

A

A scoring system developed from pooling data from 6 prospective studies. It helps estimating 5 year rupture risk by risk factor status.

56
Q

PHASES give feedback in terms of 5 year rupture risk based on points on the score. GIve the highest and lowest values.

A

2p = 0.4% risk
12p = 17.8% risk

57
Q

PHASEs rupture risk score have 5 predictors. Which?

A

P- population
USA/EU -0p
Japan -3p
Finnish - 5p

H- Hypertension
Yes - 1p

A- Age Obs! not same as rec. for treatment
over 70yo - 1p

S- Size
less than 7 -0p
7-9 -3p
10-19.9 - 6p
20mm - 10p

E- earlier rupture
Yes -1p

58
Q

Recommended follow up for untreated UIAs

A

MRA/CTA annual. If no growth, reduced frquency might be considered.

59
Q

What is recomended if growth is seen on follow up MRA(TOF)/CTA?

A

Intervention (surg or ai)

60
Q

Why is catheter angiogram recomended for follow up?

A

The risks are seen as too high for this purpose

61
Q

When is clipping indicated for mycotic aneurysms?

A
  • Failure of reducing size with 6 week antibiotics.
  • SAH
62
Q

What is the risk with a Cathether angiogram?

A

1293, 1339,

Vascular (10 decks)

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