Aneurysms and SAH Flashcards
Incidens of aSAH?
8/100.000
What is Terson syndrome?
A concurrent intraocular hemorrhage within the vitreous humor. 4-27% of aSAH
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?
11-33%!!
Median age SAH and mean age?
58yo, 50-55yo
Contributing factors for an intracranial aneurysm to rupture?
- age over 60
- posterior circulation a
- size over 5mm
Risk factors for aneurysmal SAH
- hypertension
*cigarette smoking - previous aSAH?
- alkohol
- Sympathomimetic drugs
*estrogen deficiency?
Causes of non-aneurysmal SAH?
- perimesencephalic
- Occult
- Vascular malformations (AVM or dAVF)
- Dissection
- Cocain abuse
- Cerebral amyloid angiopathy
- Cerebral venous thrombosis
- Sickle cell anemia
- MoyaMoya
- Cerebral vasculitis
What two counties have higher burden of aSAH?
Finland and Japan.
What is a dolichoectasic aneurysm?
elongated, tortuous, and sometimes dilated vessel segments
When should an LP be done in case of negative CT and high suspicion of SAH?
A lumbar puncture should ideally be performed 6 hours after the initial Head CT to detect the presence of xanthochromia.
How frequent is hcph after aSAH ?
about 25% up to 30%
How many% of aSAH pt have a radiographically vasospasm?
60%
How many patients have a clinical manifestation of vasospasm?
about 30%
What is TCD?
transcranial doppler
When is EVD indicated?
in patients with enlarged ventricles on CT or with WFNS scale score ≥3;
When is the highest risk of re-bleeding after aSAH?
The most significant risk of rebleeding and mortality is within the first 6 hours of the initial hemorrhage.
Riskfactors for rebleeding?
*Elevated systolic blood pressure,
*poor Hunt-Hess grades, *intracerebral or intraventricular hematomas,
*aneurysms > 10 mm in size,
*aneurysms in the posterior circulation
How many % of rebleedings occur within 3h and 6h (from aSAH)?
1/3 and 1/2
What is the mortality rate in rebleeding cases?
50-70%
What is the daily rebleeding risk after aSAH if not treated from 24h after ictus to day 13?
1.5% daily.
what is the yearly rebleeding risk after 6 mo from ictus?
3% per year
What is the yearly mortality rate 6 mo after aSAH?
2%/yr
What is the risk of rebleeding after securing the aneurysm?
1%
What antifibrinolytic drug should be given after aSAH?
Tranexamic acid, 1g immidiately and then 1g/6h in 72h or until treatment.
What are the two prefered substances for BP control after aSAH?
- Labetalol
- Hydralazine
What is the only known vasospasm preventing drug?
Nimodipine. 60mg Q4h for 21 days. if hypotension is a problem, give 30mg q 2h.
What is Clazosentan?
An endothelin antagonist found to have an effect on radiographic vasospasm. Under study for clincal benefit.
Does statins have a role in SAH?
nope. But no problem either if taken since before.
What is the accepted clinical parxis for starting VTE profylaxis after aSAH surgery?
24h-48h.
What is WFNS used for?
It describes the clinical presentation of SAH patients and help predict recovery and response to treatment.
How many percent of patients w SAH died before evaluation in hospital (published 2017)
18%
What is neurogenic pulmonary edema?
p 1237
what is neurogenic stunned myocardia?
How many survivors have moderate to severe disability?
30%
WHat are the two most predictive factors to outcome after aSAH?
- WFNS!
- age (70)
What is the most common cause of SAH at all?
trauma
What heredity is considered to be a riskfactor for aneurysm and aSAH?
more than 1 1st degree family member.
What is the prevalence of aneurysms?
uncertain data. About 1-5% of the population.
How much more common is an unruptured aneurysm in women compared to men?
1:3.
What is the mortality rate fpr aSAH with IVH?
64%
What type of visual defect occurs from compressive opthalmica aneurysm?
Nasal quadrantanopsia
What aneurysms might cause chiasmal syndromes?
- opthalmic
- a-comm
- basilar apex
Which aneurysm locations may cause facial pain syndromes mimicing trigeminal neuralgia?
- intracavernous
- supraclinoid
Prolonged time to surgery has been found to be correlated to worse outcome after aSAH. What is considered “prolonged time”?
3 days.
ultraearly coiling of aSAH in pt w HH IV/V has been shown to correlate to improved clinical outcome. What was considered ultraearly?
within 24h.
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?
1% annual risk
55% mortality after aSAH
15% Serious morbidity after aSAH
2% and 6% Surgical morbidity and mortality.
According to Greenberg 9, what are the important factors to take into decision of intervention or not for an UIA?
- 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.
Is the risk increased for UIAs if the patient has had a rupture from another aneurysm?
Yes.
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. 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.
Some rupture correlated factors are debated.
What is the debate for aneurysm size (regarding aneurysms 10mm or smaller)?
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.
What is the yearly rupture risk for 10-25mm aneurysms and giant aneurysms (more than 25mm)?
3-18% per year
and
8-50% per year.
Morphology related to rupture is more clear. What are unpleasant signs?
- precense of daughter sac
- Bottleneck shape
- Increased ratio aneurysm diameter vs parent vessel diameter.
DIscussions are ongoing about risk of rupture related to location. WHat is the present “decision” on what is truth?
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.
What is PHASES?
A scoring system developed from pooling data from 6 prospective studies. It helps estimating 5 year rupture risk by risk factor status.
PHASES give feedback in terms of 5 year rupture risk based on points on the score. GIve the highest and lowest values.
2p = 0.4% risk
12p = 17.8% risk
PHASEs rupture risk score have 5 predictors. Which?
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
Recommended follow up for untreated UIAs
MRA/CTA annual. If no growth, reduced frquency might be considered.
What is recomended if growth is seen on follow up MRA(TOF)/CTA?
Intervention (surg or ai)
Why is catheter angiogram recomended for follow up?
The risks are seen as too high for this purpose
When is clipping indicated for mycotic aneurysms?
- Failure of reducing size with 6 week antibiotics.
- SAH
What is the risk with a Cathether angiogram?
1293, 1339,
