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AIP: Headache > Subarachnoid haemorrhage > Flashcards

Subarachnoid haemorrhage Flashcards

1
Q

What are 8 aspects of the presentation of subarachnoid haemorrhage?

A
  1. Headache - sudden and severe (thunderclap)
  2. Meningism: photophobia, neck stiffness
  3. Nausea, vomiting, dizziness
  4. Imapired level of consciousness
  5. Early focal neurological signs
  6. Seizures
  7. Sentinel bleed
  8. May present with secondary head injury following collapse
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2
Q

What is the nature of the headache in SAH?

A
  • sudden and severe (‘thunderclap’)
  • radiating behind the occiput
  • associated with neck stiffness
  • time from onset to peak of headache only a few second but can be less dramatic
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3
Q

After what activity do many aneurysmal headaches occur?

A

at/after sexual intercourse (but most coital headaches are not SAHs)

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4
Q

What proportion of patients with subarachnoid bleeds are bending or lifting heavy objects at the onset of symptoms?

A

10%

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5
Q

What may be the course of impaired consciousness following SAH?

A

there may be an initial transient loss of consciousness, followed by variable impairment

patients may present in a coma

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6
Q

What makes early focal neurological signs more likely to occur following SAH?

A

concomitant intracerebral aemorrhage

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7
Q

What type of aneurysm does third nerve palsy raise the possibility of?

A

posterior communicating artery aneurysm

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8
Q

What does SAH in a person known to have fits suggest?

A

underlying AV malformation

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9
Q

What proportion of patients with documented SAH report a distinct, unusually severe headache in the days or weeks before the index bleed?

A

20-50% of patients have this possible sentinel bleed

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10
Q

What often happens with sentinel bleeds prior to the index bleed?

A

often misdiagnosed as simple headaches or migraine

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11
Q

What evidence may there be of secondary head injury following collapse from SAH?

A

blood on CT scanning

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12
Q

What are the 3 common causes of SAH and what is the distribution of these causes (%)?

A
  1. Aneurysm: 70%
  2. AV malformation: 5%
  3. No known cause in up to 20%
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13
Q

What are 4 rare causes of SAH?

A
  1. Clotting disorder/anticoagulants
  2. Tumour
  3. Vasculitis
  4. Associated with polycystic kidney disease (berry aneurysm)
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14
Q

What 3 conditions are berry aneurysms associated with?

A
  1. polycystic kidney disease
  2. Ehlers-Danlos syndrome
  3. Coarctation of the aorta
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15
Q

What is the scale that allows grading of SAH at presentation and thereafter?

A

Hunt and Hess scale

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16
Q

What are the 5 grades of the Hunt and Hess scale to grade SAH?

A
  1. Grade 1: asymptomatic or minimal headache + slight neck stiffness
  2. Grade 2: moderate or severe headache with neck stiffness, but no neurological deficit other than cranial nerve palsy
  3. Grade 3: drowsiness with confusion or mild focal neurology
  4. Grade 4: stupor with moderate to severe hemiparesis or mild decerebrate rigidity
  5. Grade 5: deeply comatose with severe decerebrate rigidity
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17
Q

How does the mortality of SAH vary with the Hunt and Hess grade?

A

Prognosis best in grade 1 (<5%), worst in grade 5 (mortality 50-70%)

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18
Q

What happens to Hunt and Hess grade if a patient with SAH deteriorates further after initial presentation?

A

worse prognosis; should be re-graded on Hunt and Hess scale

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19
Q

Even if a headache isn’t extremely severe, what should make you have a high suspicion for SAH?

A

first and worst headache in someone not prone to headaches

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20
Q

If a patient has recurrent thunderclap headaches, what may this herald?

A

reversible cerebral vasoconstriction syndrome (need CT or MRA)

i.e. not SAH

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21
Q

What are 5 broad aspects of the management of a patient with SAH?

A
  1. Confirm diagnosis
  2. Stabilise the patient
  3. Specific therapies
  4. Observe for deterioration+ attempt to reverse
  5. Refer for definitive treatment
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22
Q

What are 8 things that initially stabilising a patient with SAH may involve?

A
  1. Protect airway - lie drowsy patient in recovery position
  2. Give oxygen if drowsy
  3. Consider measures to reduce ICP if signs suggest it is raised
  4. Treat seizures with usual drugs
  5. Correct hypotension with colloid or inotropes
  6. Nurse in quiet room to avoid hypertension, sedatives, stool softeners to avoid straining
  7. ECG monitoring and treat dysrhythmias if compromise BP or threaten thromboembolism
  8. Take blood for clotting screen, U+Es
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23
Q

What should you be careful of when considering measures to reduce ICP if there are signs it is raised?

A

avoid dehydration and hypotension

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24
Q

What shoud you be careful of when treating seizures in SAH?

A

beware of over-sedation and hypotension

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25
Q

What are 2 things that should be used to correct hypotension in SAH?

A
  1. Colloid or
  2. Inotropes
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26
Q

What are 4 measures to take to avoid hypertension in SAH?

A
  1. Nurse patient in a quiet room
  2. Sedatives if required
  3. Stool softeners to aoid straining
  4. Nimodipine given once diagnosis established to reduce vasospasm + BP
27
Q

When should dysrhythmias be treated in SAH?

A

if they compromise BP or threaten thromboembolism

28
Q

What are 2 important blood tests to initially perform in SAH?

A
  1. Clotting screen - if bleeding diathesis suspected
  2. U+Es - assess for dehydration, potassium (dysrhythmia susceptibility), hyponatraemia/SIADH
29
Q

What are 3 types of specific therapies which may be needed for subarachnoid haemorrhage management?

A
  1. Nimodipine: reduce vasospasm + cerebral ischaemia
  2. Analgesia: codeine phosphate 30-60mg every 4-6h
  3. Anti-emetics

latter 2 for awake patients

30
Q

What are the 2 important methods required to confirm the diagnosis of SAH?

A
  1. Urgent HR-CT (high resolution CT)
  2. LP - if CT normal but history highly suggestive
31
Q

What proportion of patients with SAH will be detected on HR-CT if performed within 24h?

A

95%

32
Q

As well as confirming the diagnosis, what additional benefit of performing CT in SAH is there?

A

valuable info regarding possible location of aneurysm, may even demonstrate AV malformation

may display concomitant intracerebral and/or intraventrilcular bleeds

33
Q

When is lumbar puncture indicated in suspected SAH?

A

not usually required, unless CT scan normal but history highly suggestive

examine CSF for blood (xanthochromia)

34
Q

How does LP indicate if SAH has occurred?

A
  • blood in CSF may be from traumatic tap; if this is the case, there may be diminishing numbers of red cells in each successive tube of CSF (but not always reliable)
  • if blood has been present for >6h, supernatant should be xanthochromic after centrifugation
  • may also have normal or raised opening pressure
35
Q

What should be done once a diagnosis of SAH has been confirmed?

A

discuss with regional neurosurgeons

grade 1 and 2 patients should be transferred as soon as posible for surgery - outcome likely improved by early transfer

36
Q

What is the benefit of neurosurgery for SAH?

A

will prevent re-bleeding

37
Q

What is usually the management of poor-prognosis SAH patients?

A

usually conservative (surgery unrewarding)

suitability for surgery should be re-assessed if condition improves

38
Q

What type of course of nimodipine is given in patients with SAH?

A

60mg PO (IV if comatose) every 4h

39
Q

Why is nimodipine usually given PO in conscious patients?

A

IV therapy is costly and requires central venous access

40
Q

What type of analgesia should be given in conscious patients with SAH?

A

codeine phosphate 30-60mg every 4-6h

41
Q

What should be done in order to observe for deterioration in SAH?

A

neurological observations should be performed regularly (GCS, pupil size and reactivity, limb movements, respiratory rate, heart rate, BP, temperature, sats)

42
Q

What must be done if any deterioration in neurological observations occurs after SAH?

A

CT scan should be performed

43
Q

What are 3 possible causes of deterioration in a patient who has had SAH?

A
  1. Cerebral ischaemia
  2. Re-bleeding
  3. Acute hydrocephalus
44
Q

What is the nature of cerebral ischaemia in SAH?

A

usually insidious and multifocal, may give rise to focal and/or global neurological deterioration

45
Q

What may cerebral ischaemia following SAH present with?

A

focal and/or global neurologicla deterioration

46
Q

What may be the consequences of re-bleeding following SAH?

A

may be immediately fatal or lead to apnoea

47
Q

What may be the initial management of patients with re-bleeding causing apnoea following SAH?

A

assisted ventilation for 1h may return spontaneous breathing

48
Q

What is the risk in patients who re-bleed following SAH and what should be the definitive management?

A

at high risk of further bleeding; should be considered for emergency aneurysm clipping

49
Q

How may acute hydrocephalus following SAH be treated?

A

with ventricular drainage

  • external ventricular drain (CSF diverted into bag at bedside)
  • if required, long-term ventriculo-peritoneal shunt (VPS)
50
Q

What is the most comon cause of SAH?

A

head injury - traumatic SAH

51
Q

What ECG changes may sometimes be seen in SAH?

A

ST elevation

52
Q

What finding on CT confirms a diagnosis of SAH?

A

acute blood (hyperdense/bright on CT) distributed in the basal cisterns, sulci and in severe cases the ventricular system

53
Q

When should LP ideally be performed when being used to confirm SAH?

A

at least 12 hours following onset of symptoms - to allow development of xanthochromia

54
Q

When is it important to remember that a referral to neurosurgery is made in SAH?

A

as soon as SAH confirmed (CT/LP)

55
Q

After spontaneous SAH is confirmed, what is the aim of investigations subsequently?

A

to identify a causative pathology that needs urgent treatment: CT angiogram ± digital subtraction angiogram

56
Q

What are 2 types of imaging which may be used once a diagnosis of SAH is confirmed, to identify a cause (if it was spontaneous SAH)?

A
  1. CT intracranial angiogram (to identify vascular lesion e.g. aneurysm or AVM)
  2. ± digital subtraction angiogram (catheter angiogram)
57
Q

Within what time frame is surgical intervention indicated for SAH, and why?

A

within 24h - to prevent rebleeding

58
Q

How are most intracranial aneurysms treated definitively? What is the alternative?

A
  1. with a coil by interventional neuroradiologists
  2. minority require craniotomy and clipping by a neurosurgeon
59
Q

What length course of nimodipine is used to prevent vasospasm?

A

21-day course

60
Q

How does nimodipine work?

A

CCB that works preferentially on cerebral vessels to reduce vasospasm (and consequent cerebral ischaemia)

61
Q

What are 6 complications of aneurysmal SAH?

A
  1. Re-bleeding
  2. Vasospasm (delayed cerebral ishaemia)
  3. Hyponatraemia due to SIADH
  4. Seizures
  5. Hydrocephalus
  6. Death
62
Q

When does re-bleeding most commonly occur after SAH?

A

first 12 hours

63
Q

After what time frame does delayed cerebral ischaemia due to vasospasm usually occur after SAH?

A

7-14 days after onset

64
Q

What are 3 important predictive factors in SAH?

A
  1. Conscious level on admission
  2. Age
  3. Amount of blood visible on CT head

AIP: Headache (10 decks)

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