Subarachnoid hemorrage –eso guidelines for management

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Subarachnoid hemorrage –eso guidelines for management

  1. 1. Dr.Abdulgafoor.M.T ;MD ICU ,ALKHOR HOSPITAL
  2. 2. Incidence:9 per 100000(Japan &Finland 15-17) Mortality:60% within 6 months with conservative treatment One third die from rebleeding within 6 months 1.6 times higher in females Median age of onset 50-60 years 90%of aneurysms less than 10mm and 90% in ACA circulation EPIDEMIOLOGY
  3. 3. Statement on Definition  Ruptured intracranial aneurysm’ (RIA)  Unruptured intracranial aneurysm’ (UIA); asymptomatic’ or ‘symptomatic’  A symptomatic UIA usually causes brain nerve palsy or rarely can cause arterial embolism  Asymptomatic UIAs are usually found incidentally DEFINITIONS BY ESO (EUROPEAN STROKE ORGANIZATION)
  4. 4. Hunt& Hess grading 1.Asymptomatic, mild headache, slight nuchal rigidity 2.Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy 3.Drowsiness / confusion, mild focal neurologic deficit 4.Stupor, moderate-severe hemiparesis 5.Coma, decerebrate posturing CLINICAL APPEARANCE &GRADING
  5. 5. gra de GCS Focal neurological deficit 1 15 Absent 2 13–14 Absent 3 13–14 Present 4 7–12 Present or absent 5 <7 Present or absent WFNS(WORLD FEDERATION OF NEURO SURGEONS) GRADING
  6. 6. Grade(1) GCS 15 Grade(2) GCS 11 to 14; Grade(3) GCS 8 to10 Grade (4) GCS 4 to 7; Grade (5) GCS 3. PAASH(PROGNOSIS ON ADMISSION OF ANEURYSMAL SUBARACHNOID HEMORRHAGE) GRADING Better correlated with outcome than WFNS
  7. 7. FISCHER GRADING Grade Appearance of hemorrhage 1 None evident 2 Less than 1 mm thick 3 More than 1 mm thick 4 Diffuse or none with intraventricular hemorrhage or parenchymal extension
  8. 8. Modified by Claassen and coworkers, reflecting the additive risk from SAH size and accompanying Intraventricular hemorrhage 0 – none 1 - minimal SAH w/o IVH 2 - minimal SAH with IVH 3 - thick SAH w/o IVH 4 - thick SAH with IVH
  9. 9. Recommendation • It is recommended that the initial assessment of SAH patients,and therefore the grading of the clinical condition, is done by means of a scale based on the GCS • The PAASH scale performs slightly better than the WFNS scale, which has been used more often (Grade3 Level C) RECOMMENDATION-GRADING
  10. 10. Patient factors:Age,Hypertension,High systolic BP,Alcohol consumption,smoking (for delayed cerebral ischemia) Aneurysm factors:Size and site of Aneurysm Disease associated:Rebleeding,Delayed cerebral ischemia,Hydrocephalus Treatment associated:Aneurysm clipping or coiling Complications due to prolonged bed rest. PREDICTORS OF OUTCOME
  11. 11. STATEMENT-RISK FACTORS
  12. 12. 10% in first degree relatives 5-8% in first or second degree Family history of Aneurysm in 10% Polycystic kidney disease is associated RECOMMENDATION-SCREENING
  13. 13. CT is useful in the early period .Afterward redistribution and resorption of blood occurs.After 5 days of bleed CT can detect only 85% and after 2 weeks 30% MRI with flair technology comparable to CT in the early period and superior in the late stage Water clear CSF during LP rules out SAH within 2-3 weeks Gold standard :Cerebral panangiography.(sensitivity 0.77-0.97 &Specificity0.87-1) DIAGNOSIS
  14. 14. RECOMMENDATION-DIAGNOSIS
  15. 15. – Intensive continuous observation at least until occlusion of the aneurysm – Continuous ECG monitoring Hourly  GCS,  focal deficits,  blood pressure and  temperature at least every hour MONITORING
  16. 16. Statement on Physical Management  Avoid situations that increase intracranial pressure, The patient should be kept in bed Antiemetic drugs, laxatives and analgesics should be considered before occlusion of the aneurysm (GCP) STATEMENT-TREATMENT
  17. 17.  Recommendation for Blood Glucose Management Hyperglycemia over 10 mmol/l should be treated (GCP)  Blood pressure Management Stop antihypertensive medication that the patient was using Do not treat hypertension unless it is extreme; BP limits to be set on an individual basis,depending on age , pre-SAH BP and cardiac history; systolic blood pressure should be kept below 180 mm Hg, only until coiling or clipping of ruptured aneurysm, RECOMMENDATION-TREATMENT
  18. 18. RECOMMENDATION-TREATMENT
  19. 19. RECOMMENDATION-TREATMENT
  20. 20. RECOMMENDATION-TREATMENT
  21. 21. RECOMMENDATION-TREATMENT
  22. 22. RECOMMENDATION-TREATMENT  Sizure at onset 7%  10% Develop sizure in first few weeks  Convulsive status epilepticus in 0.2%  Nonconvulsive status epilepticus in comatose patients 8%  Continuous EEG –no improvement in outcome  In one RCT outcome worst in 65% who received prophylactic antiepileptics Vs 35% in those didn’t receive .
  23. 23. RECOMMENDATION-TREATMENT
  24. 24. First few hours 15% rebleeds 24 hrs to 4 weeks:35-40% rebleeds After 4 weeks: 3% per year Case fatality rate day 1:25-30% 1 week :40-45% First Month:55-60% First Year:65% Five Year:65-70% 12%Die before reaching hospital OUTCOME
  25. 25. Included only aneurysms which can be clipped or coiled. 90%were good grades MCA aneurysms underrepresented Absolute risk reduction of death and disability after 1 year 6.9%(23.7% Vs 30.6%) Reduction in relative 5 year mortality in favour of coiling Retreatment more in coiling(17.4% Vs 3.8%) For young patients below 40 years clipping better ISAT STUDY
  26. 26. RECOMMENDATIONS-INTERVENTION
  27. 27. RECOMMENDATIONS-TREATMENT
  28. 28. HYDROCEPHALUS
  29. 29. RECOMMENDATION
  30. 30. RECOMMENDATION-TREATMENT
  31. 31. RECOMMENDATION-TREATMENT Triple H therapy: can cause increased cerebral oedema, haemorrhagic transformation in areas of infarction , reversible leucencephalopathy , myocardial infarction and congestive heart failure.
  32. 32. SAH WITHOUT ANEURYSM
  33. 33. Asymptomatic incidental aneurysm Symptomatic aneurysm Aneurysms in SAH patients(multiple aneurysm) UNRUPTURED ANEURYSM
  34. 34. RECOMMENDATION-UNRUPTURED INTRACRANIAL ANEURYSMS

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