Pharmacological Management of Aneurysmal Subarachnoid Hemorrhage

Question 1

What is a subarachnoid hemorrhage (SAH)

Answer 1

Extravasation of blood into the subarachnoid space

Question 2

What are the modifiable risk factoors for aSAH

Answer 2

Hypertension. smoking, alcohol abuse, drug abuse (cocaine)

Question 3

What are the non-modifiable risk factors

Answer 3

Family history, being male then women younger than 50, being black, age greater than 50

Question 4

What are the signs and symptoms of aSAH

Answer 4

“Worst headache of my life”, N/V, loss of consciousness, focal deficitys, nuchal rigidity or neck pain, seizures

Question 5

What are the management considerations of aSAH

Answer 5

Rebleeding, Hydrocephalus, Vasopasm-Delayed cerebral ischemia, seizures, hyponatremia

Question 6

When is rebleeding at the highest risk, signs, prevention

Answer 6

first 2 to 12 hours/ another worst headache/ early intervention (surgical,endovascular), systolic blood pressure less than 160, avoid ASA/NSAIDs or anti-coagulants

Question 7

T/F: If a patient has delated intervention aminocaproic acid or tranexamic acid is reasonable (up to 72 hours)

Answer 7

True

Question 8

What is hydrocephalus, acute symptoms, chronic

Answer 8

Blood in the CSFcauses an accumulation of cerebospinal fluid increasing the pressure in the skull, decreased consciousness with focal deficits, dementia and gait disturbances

Question 9

How is acute hydrocephalus treated, chronic

Answer 9

External ventricular drain, ventriculo-peritoneal shunt

Question 10

What is used to treat acute management of elevated intracranial pressure

Answer 10

Mannitol: 0.25-1 g/kg over 10 to 30 minutes (MUST BE administered AS 20% SOLUTION with in line filter)
Hypertonic saline 23.4%: 30 ml/dose over 20 to 30 minutes

Question 11

What should be monitored when using mannitol

Answer 11

serum osmolality is less than 320 mOsm, water balance, osmolar gap is less than 20

Question 12

T/F: Hypertonic saline at 23.4% can be given centrally or peripherally

Answer 12

False: A hypertonic solution that high would damage peripheral veins

Question 13

What must be monitored when using hypertonic saline, what is the threshold that cant be crossed

Answer 13

Na, Cl, water balance/ Serum sodium never becomes greater than 160 mEq/L

Question 14

What must be monitored when using hypertonic saline, what is the threshold that cant be crossed

Answer 14

Na, Cl, water balance/ Serum sodium never becomes greater than 160 mEq/L

Question 15

What is the primary cause of permanent injury in patients with aSAH, peak time this occurs

Answer 15

Vasospasm and Delayed cerebral ischemia/ 4-14 days after initial bleed

Question 16

What is the theorized reason vasospasm occured

Answer 16

Blood that should be in the vessel touch the outside of the vessel causing the vessel to squeeze and have less blood reach the brain

Question 17

What is the only FDA approved drug for vasospasm, how is taken and dose

Answer 17

Nimodipine: 60 mg by PO/NGT every 4 hours for 21 days/ Give within hours of initial bleed

Question 18

T/F: Nimodipine decreases the neurologic deficits associated with vasospasm but will not decrease incidience

Answer 18

True

Question 19

What needs to be done for hemodynamic augemntation

Answer 19

Euvolemia and Hypertension

Question 20

What is used to maintain euvolemia, monitor

Answer 20

0.9% NaCl/ pulmonary edema, congestive ehart failure, atrial fibrillation

Question 21

What is the goal blood pressure once the vasospasm has occured

Answer 21

SBP 180 to 220 mmHg with duration depending on symptoms

Question 22

Which drugs are given for hypertension due to vasospasm/ monitoring parameters

Answer 22

Dopamine, norepinephrine, and phenylephrine/ myocardial infarction, lactic acidosis, tissue ischemia

Question 23

What are the endovascular interventions for vasospasm

Answer 23

angioplasty/ pharmacological intra-arterial administration with verapamil, nicardipine, milrinone

Question 24

What is used to treat hyponatremia

Answer 24

3% NaCl infusions or Fludrocortisione 0.1 mg BID