SAH and ICH

Question 1

Define Subarachnoid hemorrhage

Answer 1

is the leakage of blood into the subarachnoid space and classically presents as a sudden, severe headache.

Question 2

About 75% of atraumatic subarachnoid hemorrhages are caused by a ________________

Answer 2

ruptured aneurysm

Question 3

In about 20% of cases a cause is___________

Answer 3

not identified

Question 4

The remaining causes (5%) are related to a variety of miscellaneous conditions,

Answer 4

including arteriovenous malformations, sympathomimetic drugs, and other less common causes

Question 5

__________________are focal arterial pouches typically located in areas of bifurcation of the circle of Willis.

Answer 5

Cerebral aneurysms

Question 6

larger aneurysms of what size are more likely to rupture than smaller aneurysms?

Answer 6

> 5 to 10 mm

Question 7

Patients with subarachnoid hemorrhage classically present to the ED with________________________

Answer 7

a severe headache of acute onset (termed a “thunderclap” headache) that reaches maximal intensity within seconds.

Question 8

True or false

Even if a patient is not experiencing the “worst headache of their life,” a headache that is different in intensity or quality from past headaches should raise concern for subarachnoid hemorrhage

Answer 8

True

Question 9

Subarachnoid hemorrhage can be ruled out with 100% sensitivity with implementation of the______________________________ for headache evaluation.

Answer 9

Ottawa Subarachnoid Hemorrhage Rule

Question 10

subarachnoid hemorrhage may be excluded in patients

Answer 10

under 40 years of age
without neck pain or stiffness
without a witnessed loss of consciousness
without onset during exertion
without a thunderclap headache
without limited neck flexion

Question 11

Give risk factors for SAH

Answer 11

• Hypertension
• Smoking
• Excessive alcohol consumption
• Polycystic kidney disease
• Family history of subarachnoid hemorrhage
• Coarctation of the aorta
• Marfan’s syndrome
• Ehlers-Danlos syndrome type IV
• α1-Antitrypsin deficiency

Question 12

Differential Diagnosis of Subarachnoid Hemorrhage

Answer 12

• Vascular pathology (other intracranial hemorrhage, ischemic stroke or transient isch-
emic attack, arterial dissection, venous thrombosis)
• Drug toxicity
• Infection (meningitis, encephalitis)
• Intracranial tumor
• Intracranial hypotension
• Metabolic derangements
• Primary headache syndromes (benign thunderclap headache, migraine, cluster headache)
• Hypertensive disorders

Question 13

The initial diagnostic modality of choice when subarachnoid hemorrhage is suspected is a

Answer 13

noncontrast CT of the head

Question 14

The sensitivity of CT in diagnosing subarachnoid hemorrhage is highest shortly after symptoms begin and is estimated to be 98% within_____________ of symptom onset

Answer 14

6 to 12 hours

Question 15

In patients who are neurologically intact who present with a thunderclap headache, a normal head CT within_________ of headache onset is extremely sensitive in ruling out aneurysmal subarachnoid hemorrhage

Answer 15

6 hours

Question 16

Sensitivity of CT scan decreases to about 91% to 93% at 24 hours and continues to decline rapidly thereafter, reaching______ at 1 week.

Answer 16

50%

Question 17

Most authorities recommend__________________ when a patient with suspected subarachnoid hemorrhage has a normal head CT.

Answer 17

cerebrospinal fluid (CSF) analysis

Question 18

The_______________ in the ____________ tube of CSF is commonly used to identify subarachnoid hemorrhage.

Answer 18

RBC count in the third or fourth

Question 19

Xanthochromia is a yellow appearance of the CSF due to the

Answer 19

enzymatic breakdown of blood releasing bilirubin

Question 20

Limitation of Xanthochromia test

Answer 20

it takes approximately 12 hours from hemorrhage onset for xanthochromia to develop in CSF

Question 21

True or false

normal head CT result with a positive finding of xanthochromia or elevated RBC count in tube 4 should be considered diagnostic of subarachnoid hemorrhage

Answer 21

True

Question 22

The risk of rebleeding is greatest in the first _________ and can be reduced by adequate blood pressure control.

Answer 22

2 to 12 hours

Question 23

While target pressures have not yet been established, a decrease in systolic blood pressure to a range of______________ is reasonable

Answer 23

120 to 160 mm Hg

Question 24

Avoid__________________ because they increase cerebral blood volume and intracranial pressure.

Answer 24

nitroprusside and nitroglycerin

Question 25

Vasospasm is most common____________________ after subarachnoid hemorrhage.

Answer 25

2 days to 3 weeks

Question 26

A modest protective benefit is seen with administration of nimodipine, 60 milligrams PO every 4 hours, and this therapy should be initiated within__________ of symptom onset unless contraindicated due to allergy, nonfunctioning GI tract, or hepatic disease.

Answer 26

96 hours