Management of subarachnoid haemorrhage Flashcards
Describe aneurysm formation
- Haemodynamic stress occurs, normally at the branch of a vessel
- This causes extensive inflammatory and immunological reactions
- If inflammation response attenuates then the aneurysm stabilise but if it continues then the aneurysm will grow and rupture
Where do the blood vessels in the brain reside?
In the arachnoid space
What can cerebral artery aneurysms cause?
Subarachnoid bleeding
What can arteries that penetrate the brain tissue that then rupture cause?
Intracerebral bleeding
What happens if a blood vessel ruptures through the Pia?
Parenchymal haemorrhage
What happens if a blood vessel ruptures through the arachnoid?
Subdural haemorrhage
What is aneurysmal subarachnoid haemorrhage?
•Acute cerebrovascular event
What are the predisposing factors of an aneurysmal subarachnoid haemorrhage?
- Smoking
- Female
- Hypertension
- Family history
- ADPCK, Ehlers Danlos, corctation of the aorta
what is the classical presentation of an aneurysmal subarachnoid haemorrhage?
- Acute headache with a sudden onset
- loss of consciousness, seizure, visual(ophthalmic)/speech(MCA) /limb disturbance (anterior communicating)
- Sentinel headache
What are the clinical signs of aneurysmal subarachnoid haemorrhage?
- Photophobia
- Meningism (neck stiffness due to the irritation of the meninges by blood)
- Subhyaloid haemorrhage
- Vitreous haemorrhage (red reflex lost) - terson syndrome
- Speech/limb disturbance
- Cardiovascular problems (e.g. pulmonary oedema)
Describe the appearance of subhyloid haemorrhage
- Collection of blood, fills kind of like a cup
* Between the vitreous and the retina
Explain the grading system of subarachnoid haemorrhage
- WFNS Grades
- GCS 15 = grade I
- GCS 13-14 with no deficit = grade II
- GCS with deficit = grade III
- GCS 7-12 = Grade IV
- GCS 3-6 = Grade V
What investigations should you carry out in suspected aneurysmal subarachnoid haemorrhage?
- CT to confirm diagnosis and give clues to aetiology/assess complications/prognositc
- FBC, UEs, LFT, glucose, troponin
- ECG
- CTA/MRA/DSA
- Echocardiogrpahy - tako tsubo cardiomyopathy
If a CT scan is negative in suspected SAH, what should you do?
Lumbar puncture to look for oxy haemoglobin vs bilirubin
What are the cautions of a CTA?
eGFR
What are the cautions for a MRA?
- eGFR
* Gadolinium
What are the cautions of DSA?
- Diabetes
* Also there is a risk of stroke
Explain resuscitation in patients with SAH
- Bed rest
- Fluis: 2.5-3 litres of normal saline
- Anti-embolic stockings
- Nimodipine
- analgesia
- Doppler studies
What is the role of nimodipine in SAH?
Inhibits calcium dumping, preventing late ischaemia deficit
What are the management options in SAH?
- Endovascualr (coils and others)
- Surgical clipping
- Conservative - very few
How can you check that you have successfully clipped an aneurysm?
Puncture it to ensure it isn’t filling
Describe medicine therapy after stent assisted coiling
- Use of anti platelet agents
- Clopidogrel for 3 months
- ASA for life (acetylsalicylic acid)
What are the complications of a SAH?
- Rehaemorrhage
- Delayed ischaemia
- Hydrocephalus
- Hyponatraemia
- Cardiovascular problems
- LTRI, DVT/PE, UTI
When is the risk of rehaemorrhage in SAH high?
- Incidence is highest immediately following the initial bleed
- 5-10% over 1st 72 hours
- higher in poorer grade patients
- Higher risk in larger aneurysms
Describe the treatment and morbidity of rehaemorrhage
- Immediate repair reduced the rebreeding risk
- Antifibrinolytic therapy reduces rebleeding but no benefit on poor outcome die to significantly higher incidence of cerebral ischaemia
What is the management of hydrocephalus?
- LP and EVD insertion to relieve
- If prolonged and repeated LPs are needed then shunt
- Some will just resolve by themselves
What causes hydrocephalus in SAH?
Inflammation/irrittion at the arachnoid granule level
When is delayed ischaemia likely to happen after SAH?
- Day 3-10
* Peak on day 7
What are the signs of delayed ischaemia after SAH?
- Progressive deterioration in level of consciousness associated with new deficit
- Angiographic spasm
What is the management of delayed ischaemia following SAH?
- fluid management
- Nimodipine
- Inotropes
- Angioplasty
Describe the management of hyponatraemia following SAH
- Cerebral salt wasting vs SIADH
- Establish the volume status
- Hypertonic saline
- fludrocortisone
What are the cardiopulmonary complications of SAH?
- Sympathetic stimulation and catecholamine release can lead to myocardial surgery
- Arrhythmia is 35%
- wall motion abnormalities
- Sudden death can occur
- Myocardial function usually returns to normal in 1-3 days
What are seizures post SAH often a manifestation of?
Re-rupture
Explain DVT prophylaxis post SAH
- SAH induces a prothrombotic state
- DVT in SAH in 2-18%
- Higher in poor grade
- Safer to use sequential compression devices initially then LWMH after the aneurysm is secured
- Withold LMWH 24 hours before and after intracranial procedures
