neuro pt. 2 (SAH) Flashcards
what are the 3 hematoma/hemorrhage types
subarachnoid
epidural
subdural
bleeding into the subarachnoid space
subarachnoid hemorrhage (SAH)
what is a subarachnoid hemorrhage (SAH) usually caused by?
rupture of cerebral aneurysm
where are cerebral aneurysms usually found?
circle of willis
where does a cerebral aneurysm send arterial blood?
into subarachnoid space to mix with CSF
clinical manifestations of SAH
-after rupture = “worst headache of life” or WHOL
-n/v
-dec. LOC / irritability
-signs of meningeal irritation
signs of meningeal irritation in SAH
-stiff/painful neck
-photophobia, blurred vision
-fever
-+ Kernig/Brudzinski sign
describe positive kernig and brudzinski sign for meningela irritation / SAH
KErnig = Knee Extension painful
brudziNsKi = Neck flexion leads to Knee flexion
diagnostics of SAH
based on clinical presentation
CT
-if CT -, lumbar puncture
what will CSF look like after SAH
bloody
what does cloudy CSF indicate
infection like bacterial meningitis
NOT SAH
what is used to identify exact location of SAH in preparation for surgery
cerebral angiography
SAH clinical management before surgery
prevent aneurysm from rupture!
-minimal stimulation
-pharm management (antiHTN, stool softener, antipyretic)
surgical management of SAH
SURGICAL CLIPPING
coiling
describe surgical clipping and coiling to treat SAH
clipping = clamp off aneurysm, then rupture
coiling = detachable coild fill aneurysm to prevent rupture
complication post SAH
VASOSPASM
s/sx of vasospasm post SAH
change LOC
blurred vision
HA
langauge impaired
hemiparesis
seizures
what do vasospasms cause
decreased cerebral blood flow -> dec. oxygen to brain tissue
and
accumulation of lactic acid
what is most important to ccomplish with vasospasm management?
keep cerebral artery full and open
what is the calcium channel blocker shown to improve outcomes with vasospasm?
nimodipine
when is nimodipine contraindicated for vasospasm
hypotension
describe “triple H” therapy for vasospasms
hypervolemic expansion
hemodilution
hypertension (induced)
how is hypervolemia accomplished for triple h therapy
IV crystalloids and colloids
what should be avoided when accomplishing hypervolemia with vasospasm and why
hypotonic solutions
shift fluid to brain -> cerebral edema
what should be monitored with hemodilution of triple h therapy
hemoglobin
what is the goal for induced HTN of triple h therapy
BP > 20 mm Hg over baseline
(150-160 is ideal, has to stay under 200)
what are the 3 main complications resulting from SAH?
hydrocephalus
seizures
rebleeding
what causes hydrocephalus in SAH
blood clots in subarachnoid space obstruct arachnoid villi to reabsorb CSF
what may hydrocephalus after SAH require?
ventriculoperitoneal shunt (VP shunt)
what complication of SAH happens if the aneurysm is not repaired?
rebleeding
what is a device to monitor/control ICP
ventriculostomy
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
a) nimodipine
