SAH

Question 1

What is the World Federation of Neurosurgical Societies grading system for SAH?

Answer 1

Hint - GCS & motor

I - GCS 15, nil motor deficit
II - GCS 13-14, nil motor
III - GCS 13-14, motor deficit
IV - GCS 7-12, +\- motor deficit
V - GCS 3-6, +\- motor deficit

Question 2

What are some of the Post-op complications of a SAH?

Answer 2

Hint - Hb, ventricles, nimodo, penumbra, Na

• rebleeding
• Hydrocephalus
• Vasospasm
• delayed cerebral ischaemia
• sodium imbalance

Question 3

How do you prevent vasospasm in the post-op SAH patient?

Answer 3

Hint - CaB, CK

• Nimodipine 60mg 4hourly
• continue statin

Question 4

How do you treat vasospasm in the post-op SAH patient?

Answer 4

Hint - MAP, Balloon, artery

• Haemodynamic augmentation
• Balloon angioplasty
• Intra-arterial administration of vasodilators

Question 5

What issues with sodium imbalance can occur Post-op SAH?

Answer 5

Hint - DM, waste, inapprops

• Cranial diabetes insipidus (CDI)
• Cerebral salt wasting (CSW)
• Syndrome of inappropriate ADH (SIADH)

Question 6

When would you consider a decompressive hemicraniectomy in a stroke patient?

Answer 6

Hint - 60, MCA >15, 1a NIHSS, 50% MCA

• Aged 60 years or under
• Clinical deficits suggestive of infarction in the territory of the MCA, with a score on the NIHSS of above 15
• Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS
• Signs on CT of an infarct of at least 50% of the MCA territory, with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume >145 cm3 as shown on diffusion-weighted MRI

Question 7

Describe the A-E management of a SAH?

Answer 7

Hint - A-E

A- intubated if GCS <8
B - Pa02 >13, PC02 5-5.5
C - high normal BP 120-160, CPP >70-80, avoid above 180/MAP >110 start nimodipine 30mg 2° and increase to 60mg 4°, use IV fluids and NORAD to avoid hypotension, labetolol if still HTN
D- fentanyl and prop to sedate, BM 6-10, head to 30°
E - avails pyrexia, Na 135-145, watch for polyuria, SCDS

Question 8

When is the ideal time to clip an aneurysm, if coiling is not appropriate?

Answer 8

10-12 days when the tissues are less friable. However this depends of the risk of an unsecured aneurysm

Question 9

When is microsurgical clipping more appropriate in SAH?

Answer 9

Hint - middle, neck, beanstalk, distal

MCA aneurysm
Wide necked
Giant aneurysm
Distal segmental lesions