Subarachnoid haemorrhage

Question 1

Describe aneurysm formation in ASAH?

Answer 1

• Haemodynamic stress
• Inflammatory and immune reactions in unruptured aneurysms

Question 2

What is pictured here?

Answer 2

Right temporal haematoma secondary to ruptured MCA aneurysm

Question 3

What are the predisposing factors for an aneurysmal SAH?

Answer 3

• Smoking
• Female sex
• Hypertension
• Family history
• Coarctation of the aorta

Question 4

Describe the presentation of ASAH?

Answer 4

• Seizures
• Sentinal headache
• Loss of consciousness
• Vision, speech, limb disturbances

Question 5

Describe clinical signs that suggest ASAH?

Answer 5

• Photophobia
• Subhyaloid haemorrhages
• Vitreous haemorrhages (Terson’s syndrome)

Question 6

What is the grading system used for SAH?

Answer 6

• Grade I = GCS 15
• Grade II = GCS 13-14 without deficit
• Grade III = GCS 13-14 with deficit
• Grade IV = GCS 7-12
• Grade V = GCS 3-6

Question 7

Describe the use of a CT scan when investigating SAH?

Answer 7

• Confirms diagnosis
• Clues to cause
• Visualise complications (infarction, haematoma, hydrocephalus)
• Fisher grade prognosis

Question 8

Name some other investigations in to SAH?

Answer 8

• Echo
• ECG changes
• Hyponatraemia
• Elevated troponin levels

Question 9

Describe resuscitation following SAH?

Answer 9

• Saline
• Bed rest
• Analgesia
• Anti-embolic stockings
• Nimodipine via central line

Question 10

Describe the management of ASAH?

Answer 10

• Surgical clipping
• Endovascular (coils, stents and glue)
• Conservative

Question 11

What would be done for an Anterior Communicating Artery Aneurusm?

Answer 11

Fenestrated clips (clipping)

Question 12

What can be done to counter aneurysm necks which are too large for a standard clip?

Answer 12

• Multiple clips
• Clips with longer blades

Question 13

Name an endovascular treatment of a brain aneurysm?

Answer 13

Detachable coils

Question 14

Name some complications associated with endovascular treatments of cerebral aneurysms

Answer 14

• Rehaemorrhage
• Pulmonary embolism

Question 15

Describe Rehaemorrhage as a complciation of endovascular treatment of cerebral aneurysms?

Answer 15

• Incidence highest immediately following initial bleed
• Higher in poor grade patients and large aneurysms
• Immediate repair reduces rebleeding risk

Question 16

Describe how you would treat hydrocephalus as a complication of cerebral aneurysm treatment)?

Answer 16

• Hourly external ventricular drainage
• Shunt

Question 17

Describe delayed ischaemia post-cerebral ischaemia treatment?

Answer 17

• Day 3-10 after treatment
• Progressive deterioration with new deficit

Question 18

How would you treat delayed ischaemia post-cerebral ischaemia treatment?

Answer 18

• Fluid management
  
  • Colloid infusions
• Nimodipine
• Inotropes
• Angioplasty

Question 19

What types of angioplasty can be used to treat delayed ischaemia?

Answer 19

• Balloon angioplasty
• Intra-arterial nimodipine

Question 20

How would you treat hyponatraemia as a result of cerebral aneurysm treatment?

Answer 20

• Hypertonic saline
• Fludrocortisone

Question 21

Name some cardiopulmonary complications which can result following treatment of a cerebral aneurysm?

Answer 21

• Sympathetic stimulation and catecholamine can injury heart
• Elevations of troponin
• Arrythmias
• Sudden death
• Myocardial function usually returns to normal within 3 days

Question 22

Describe Seizures associated with ASAH?

Answer 22

• Some patients sufffer seizure after initial aneurysm rupture
• Can be a sign of re-rupture

Question 23

Describe DVT prophylaxis with SAH?

Answer 23

• SAH induces prothrombotic state
• Sequential compression devices
• LMWH after aneurysm has been secured

Question 25

What is Terson’s syndrome?

Answer 25

Vitreous haemorrhage in the presence of SAH