Neuro Emergencies: SAH Flashcards
A SAH is bleeding that occurs where?
between the pia on the surface of the brain, and the arachnoid layers of the meninges
Risk Factors for SAH include
Cigarette smoking
HTN
ETOH
Genetic risk
Estrogen deficiency
Sympathomimetic drugs
Coagulopathy
Genetic risk factors for SAH include
Connective tissue d/o
Familial occurrence (In individuals w/ >/= two 1* relatives w/ known cerebral aneurysms, there is a 12% prevalence of harboring a cerebral aneurysm)
Autosomal dominant polycystic kidney disease
Marfan Syndrome
Ehlers-Danlos Syndrome
Causes of Subarachnoid Hemorrhages
Intracranial aneurysms
Trauma
Vascular malformations
Arterial dissection
Types of Intracranial Aneurysms
Saccular
Mycotic
Fusiform
Clinical Manifestations of SAH
Sudden severe headache (can have sentinel headache)
Altered LOC
Seizure
N/V
Meningisums
Cranial Nerve palsy
Focal neurological deficit
Normal exam
Coma
Systemic Complications After SAH
Early brain injury after aneurysm rupture includes
Elevated ICP w/ decreased CPP
Small and large artery constriction and thrombosis
Impaired autoregulation
Inflammation w/ cell death by necrosis and apoptosis
Cerebral edema
Blood-brain barrier disruption
Systemic Complications After SAH
Other
ECG changes
Myocardial stunning
Neurogenic pulmonary edema
SIRS
Care continuum of the patient w/ aSAH
Early Brain Injury requires?
Acute resuscitation
Emergency dx
Prevent rebleeding
treat hydrocephalus
manage elevated ICP
Manage seizures
Care continuum of the patient w/ aSAH
Delayed Brain Injury can include?
Delayed cerebral ischemia
Sodium dysregulation
systemic complications
fever and temp management
glucose management
nutritional support
Care continuum of the patient w/ aSAH
Recovery should include?
Acute rehab
HA and Seizure management
Mnitoring of aneurysms
screening for cognitive and mood d/o’s
long-term outcomes
Diagnosis Imaging
Head CT (99% sensitive and specific w/n 6h of symptom onset)
CTA
Digital Subtraction Angiography (DSA)
What is the Gold standard for evaluation of cerebrovascular anatomy and aneurysm geometry and can aid in decision making on the choice of optimal treatment modality?
Digital subtraction angiography (DSA)
Diagnosis Lab Studies?
BMP
PT/INR, PTT
CBC
troponin
Type and Screen
UDS
HCG (if appropriate)
Diagnosis bedside studies?
ECG
+/- CXR
When is a Lumbar Puncture indicated?
Sensitivity?
When clinical suspicion of aSAH is high and head CT is negative
99% sensitive when performed 12 hrs after symptom onset
SAH Grading System
Hunt and Hess Classification of SAH
Grade 1 =?
Asymptomatic, or minimal HA; slight nuchal rigidity
SAH Grading System
Hunt and Hess Classification of SAH
Grade 2 =?
Moderate to severe HA, nuchal rigidity; no neuro deficits (apart from cranial nerve palsy)
SAH Grading System
Hunt and Hess Classification of SAH
Grade 3 =?
Drowsiness, confusion, or mild focal deficit
SAH Grading System
Hunt and Hess Classification of SAH
Grade 4 =?
Stupor, moderate to severe hemiparesis; possible early decerebrate posturing
SAH Grading System
Hunt and Hess Classification of SAH
Grade 5 =?
Deep coma, decerebrate posturing, moribund
SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade I
GCS score?
Motor Deficit?
15
absent
SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade II
GCS score?
Motor Deficit?
14-13
absent
SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade III
GCS score?
Motor Deficit?
14-13
present
SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade IV
GCS score?
Motor Deficit?
12-7
present or absent
SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade V
GCS score?
Motor Deficit?
6-3
present or absent
SAH Grading System
Modified Fischer Scale is based on what?
Head CT results
SAH Management
ABC considerations?
BP control until when? Goal?
Reversal of?
Activity orders?
Antifibrinolytics usefulness?
What to do with hydrocephalus?
May need intubation; arrhythmias are common
aneurysm obliteration; Maintain SBP < 160 or MAP < 110
Anticoagulnts
Bed rest
Routine use of antifibrinolytic therapy is not useful to improve functional outcomes
Treat hydrocephalus (consider osmotic therapy)
SAH Management
First line of vasospasm prevention administer what? dose? frequency?
Nimodipine 60mg q4 hrs
SAH Management
Consider surgical intervention to evacuate what?
hematoma
SAH Management
Antiepileptic medications should be given to patients with? (4)
What to administer? dose? frequency? duration?
MCA aneurysm
high clinical/radiological grade (HH grade >3, fisher grade III/IV)
cortical infarction
hydrocephalus has been associated w/ an elevated seizure risk
Levetiracetam 500mg BID x 3 days
Hydrocephalus Management
CSF fluid diversion can be accomplished with?
EVD
Lumbar drain
Surgical management includes?
Surgical clipping
Endovascular management includes
endovascular coiling
Endovascular stent
Post treatment imaging
In pts w/ aSAH who have undergone aneurysm repair, perioperative cerebrovascular imaging is recommended to identify what?
remnants or recurrence of the aneurysm
Vasospasm
Related to a number of pathological processes which are?
Endothelial damage and smooth muscle cell contraction resulting from spasmogenic substances generated during lysis of subarachnoid blood clots
Changes in vascular responsiveness
Inflammatory or immunological reactions of the vascular wall
Vasospasm
Typical onset occurs when?
Peaks when?
Resolves by day?
Major source of what?
Accounts for what % of death in pts surviving treatment after SAH?
4-5 days
4-10 days
21
delayed cerebral ischemia (DCI)
nearly 50%
Clinical Manifestations of Vasospasm include?
Focal neurological deficits
Global Neurological Changes
Nonspecific findings
Clinical Manifestations of Vasospasm
Focal Neurological deficits such as?
Hemiparesis
Aphasias
Clinical Manifestations of Vasospasm
Global Neurological Changes such as?
Confusion or agitation
stupor or coma
Clinical Manifestations of Vasospasm
Nonspecific findings such as?
Fever
HA
Hyponatremia
Vasospasm Diagnosis can be accomplished with?
Clinical diagnosis
cerebral angiography
CT angio or CT perfusion
cEEG
Treatment of Vasospasm includes
Blood pressure augmentation
Euvolemia
Balloon Angioplasty
Endovascular vasodilators
Transcranial Dopplers
Which method of treatment for vasospasm is no longer used?
Triple H therapy
1. HTN
2. Hemodilution
3. Hypervolemia
SAH Management includes?
Neurological monitoring
No hypotonic fluids
Aggressive fever control
Glucose management
VTE prophylaxis (LMWH 40 mg vs Heparing 5000 u BID or TID)
Blood transfusion to treat anemia
Correction of Hyponatremia (Hypertonic Saline, Fludrocortisone 0.1mg TID)
Dysphagia Screening
Early mobilization w/n the 1st 4 days after aneurysm is secured
Hyponatremia in SAH - SIADH
Serum Osmolality
Urine Osmolality
BUN
HR
CVP
Treatment
low/normal
high
normal
normal
normal
Avoid excess PO fluids; conivaptan
Hyponatremia in SAH - CSW
Serum Osmolality
Urine Osmolality
BUN
HR
CVP
Treatment
Normal/high
high
rising
tachycardia
low
isotonic or hypertonic saline
