neuro pt. 2 (SAH)

Question 1

what are the 3 hematoma/hemorrhage types

Answer 1

subarachnoid
epidural
subdural

Question 2

bleeding into the subarachnoid space

Answer 2

subarachnoid hemorrhage (SAH)

Question 3

what is a subarachnoid hemorrhage (SAH) usually caused by?

Answer 3

rupture of cerebral aneurysm

Question 4

where are cerebral aneurysms usually found?

Answer 4

circle of willis

Question 5

where does a cerebral aneurysm send arterial blood?

Answer 5

into subarachnoid space to mix with CSF

Question 6

clinical manifestations of SAH

Answer 6

-after rupture = “worst headache of life” or WHOL
-n/v
-dec. LOC / irritability
-signs of meningeal irritation

Question 7

signs of meningeal irritation in SAH

Answer 7

-stiff/painful neck
-photophobia, blurred vision
-fever
-+ Kernig/Brudzinski sign

Question 8

describe positive kernig and brudzinski sign for meningela irritation / SAH

Answer 8

KErnig = Knee Extension painful
brudziNsKi = Neck flexion leads to Knee flexion

Question 9

diagnostics of SAH

Answer 9

based on clinical presentation
CT
-if CT -, lumbar puncture

Question 10

what will CSF look like after SAH

Answer 10

bloody

Question 11

what does cloudy CSF indicate

Answer 11

infection like bacterial meningitis
NOT SAH

Question 12

what is used to identify exact location of SAH in preparation for surgery

Answer 12

cerebral angiography

Question 13

SAH clinical management before surgery

Answer 13

prevent aneurysm from rupture!
-minimal stimulation
-pharm management (antiHTN, stool softener, antipyretic)

Question 14

surgical management of SAH

Answer 14

SURGICAL CLIPPING
coiling

Question 15

describe surgical clipping and coiling to treat SAH

Answer 15

clipping = clamp off aneurysm, then rupture
coiling = detachable coild fill aneurysm to prevent rupture

Question 16

complication post SAH

Answer 16

VASOSPASM

Question 17

s/sx of vasospasm post SAH

Answer 17

change LOC
blurred vision
HA
langauge impaired
hemiparesis
seizures

Question 18

what do vasospasms cause

Answer 18

decreased cerebral blood flow -> dec. oxygen to brain tissue
and
accumulation of lactic acid

Question 19

what is most important to ccomplish with vasospasm management?

Answer 19

keep cerebral artery full and open

Question 20

what is the calcium channel blocker shown to improve outcomes with vasospasm?

Answer 20

nimodipine

Question 21

when is nimodipine contraindicated for vasospasm

Answer 21

hypotension

Question 22

describe “triple H” therapy for vasospasms

Answer 22

hypervolemic expansion
hemodilution
hypertension (induced)

Question 23

how is hypervolemia accomplished for triple h therapy

Answer 23

IV crystalloids and colloids

Question 24

what should be avoided when accomplishing hypervolemia with vasospasm and why

Answer 24

hypotonic solutions
shift fluid to brain -> cerebral edema

Question 25

what should be monitored with hemodilution of triple h therapy

Answer 25

hemoglobin

Question 26

what is the goal for induced HTN of triple h therapy

Answer 26

BP > 20 mm Hg over baseline
(150-160 is ideal, has to stay under 200)

Question 27

what are the 3 main complications resulting from SAH?

Answer 27

hydrocephalus
seizures
rebleeding

Question 28

what causes hydrocephalus in SAH

Answer 28

blood clots in subarachnoid space obstruct arachnoid villi to reabsorb CSF

Question 29

what may hydrocephalus after SAH require?

Answer 29

ventriculoperitoneal shunt (VP shunt)

Question 30

what complication of SAH happens if the aneurysm is not repaired?

Answer 30

rebleeding

Question 31

what is a device to monitor/control ICP

Answer 31

ventriculostomy

Question 32

which order will prevent vasospasm?
1) nimodipine 60mg q4h
2) 0.45% NaCl @ 100
3) nitroprusside to keep systolic < 120 mmhg
4) lisinopril 10mg daily

Answer 32

a) nimodipine