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SUBARACHNOID HEMORRHAGE

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Medical, Surgical, SAH, Subarachnoid Haemorrhage, Prognosis

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SUBARACHNOID HEMORRHAGE

  1. 1. Subarachnoid HEMORRHAGE DR RAJESH T EAPEN ATLAS HOSPITAL MUSCAT
  2. 2. Definition • Subarachnoid haemorrhage is defined as bleeding into the subarachnoid space within the intracranial vault.
  3. 3. Review of anatomy
  4. 4. Incidence • The incidence of subarachnoid haemorrhage is 9.1 per 100,000 annually. • Risk increases in older age 60% higher in age above 80 • Risk of SAH is relatively higher in women over 55 years than men
  5. 5. Risk factors • Race • Sex • Age • Genetics • Smoking • Alcohol
  6. 6. Etiology • Head trauma • Intra cranial aneurysm Increased blood pressure Increased blood flow Blood vessel disorders Genetics Infections
  7. 7. Types of aneurysm • Berry (saccular)aneurysm • Giant (fusiform) aneurysm • Mycotic aneurysm • Charcot –Bouchard aneurysm • Traumatic aneurysm
  8. 8. Location
  9. 9. Pathophysiology Mass effect Rupture effect Rupture of cerebral aneurysm Bleeding into subarachnoid space Stroke syndrome develops Increased ICP
  10. 10. Risk Factors • Behavioral • Hypertension • Smoking • Alcohol Abuse • Drug Abuse • Stress • Low BMI • Non-Behavioral • Female Sex • History of previous SAH • Family history • Polycystic Disease • Age
  11. 11. How are SAH graded? GCS 15, only CN deficit if any Grade 1 No blood GCS 13-14, no deficit Grade 2 Diffuse blood, no clots & <1mm GCS 13-14, with deficit Grade 3 Clots & blood 1mm or more GCS 7-12, +/- deficit Grade 4 ICH or intra- ventricular clots GCS 3-6 +/- deficit Grade 5 Fischer grading
  12. 12. Clinical Presentation • “The worst headache of my life” • Sudden, severe onset with or without LOC (loss of consciousness) • Generally associated with nausea and vomiting, stiff neck, photophobia, restlessness and agitation • Seizures may occur (most commonly in first 24 hours) • Typically asymptomatic until rupture occurs Some times low back pain and bilateral radicular leg pain.
  13. 13. Signs • Neck stiffness • Impaired level of consciousness in some patients • Subhyaloid haemmorhage on optic funduscopy
  14. 14. Kernigs sign
  15. 15. Brudzinskis sign
  16. 16. Grading of SAH Hunt-Hass classification Category Criteria Grade 1 Asymptomatic or mild headache Grade 2 Moderate-to-severe headache, nuchal rigidity, and no neurological deficit other than possible cranial nerve palsy Grade 3 Mild alteration in mental status (confusion, lethargy), mild focal neurological deficit Grade 4 Stupor and/or hemi paresis Grade 5 Comatose and/or decerebrate rigidity GRADING/ CLASSIFICATION OF SAH:
  17. 17. Diagnosis • GOLD STANDARD: Non-Contrast head CT • Almost 100% sensitive within first 3 days • Aneurysms <3mm may not show • Lumbar Puncture – to show xanthochromia • MRI of the head • Cerebral angiography
  18. 18. CT Scan non- contrast showing blood in basal cisterns (SAH) – so called “Star- Sign”
  19. 19. Management Medical management • Acute care • If patient is comatose ventilator assistance • ABG analysis • Emergency CT scan • Cardiac monitoring • Pain management
  20. 20. • The goal of treatment is to prevent re bleeding and cerebral vasospasm • Re bleeding • Bed rest • Recombinant activator factor VII
  21. 21. • Calcium channel blocker • Smooth muscle relaxants • Triple H therapy Hypervolumia Hypertension Hemodilution
  22. 22. • Steroids • Antihypertensive • Antipyretics • Anticonvulsants • Analgesics • Sedatives • Stool softeners
  23. 23. Differential Diagnosis • Migraine • Drug Abuse • Arterial dissection • Vasculitis • Anticoagulant Use
  24. 24. Pharmacological Treatment • Monitor CVP (Central Venous Pressure) – if <7 0.9% NS bolus • Maintain SBP 90-140mmHg until aneurysm is secured (clipping or coiling) • If non-traumatic – control vasospasms with Nimodipine 60mg q4h X 21 days or 30mg q2h X21 days • Prevent seizures – levetiracetam 500mg IV Q12h • Control blood glucose levels
  25. 25. Nimodipine (Nimotop®) • Indication: Subarachanoid Hemorrhage (Hunt & Hess 1-V) • MOA: Calcium channel blocker – prevents calcium entry into smooth muscle cells during depolarization which inhibits vasoconstriction • Dose: 30mg PO q2h for 21 days OR 60mg PO q4h for 21 days • Interactions: CYP3A4 Inhibitors and Inducers • Pharmacokinetics: 95% protein bound, hepatic metabolism • Monitoring: BP, HR, Neurological improvement
  26. 26. Surgical management clipping of aneurysm
  27. 27. 22/02/2015© 2009, American Heart Association. All rights reserved. Clipping
  28. 28. Left image arrow -Angio with Large aneurysm Right image arrow – Angio showing aneurysm post clipping
  29. 29. Coiling of aneurysm
  30. 30. 22/02/2015© 2009, American Heart Association. All rights reserved. Coiling
  31. 31. Coil system embolization: immediate result Angio showing large ICA aneurysm Same aneurysm - Post GDC Coiling
  32. 32. Infectious problems in SAH patients • important to distinguish saccular aneurysms from mycotic (frequently post-bacteremic) aneurysms • postoperative infections • postoperative meningitis may be aseptic, but this is a diagnosis of exclusion • particularly a problem in the SAH patient because the hemorrhage itself causes meningeal reaction • complications of critical illness • complications of steroid use
  33. 33. Seizures in SAH patients • about 6% of patients suffer a seizure at the time of the hemorrhage • distinction between a convulsion and decerebrate posturing may be difficult • postoperative seizures occur in about 1.5% of patients despite anticonvulsant prophylaxis • remember to consider other causes of seizures (e.g., alcohol withdrawal)
  34. 34. Seizures in SAH patients • patients developing delayed ischemia may seize following reperfusion by angioplasty • late seizures occur in about 3% of patients
  35. 35. Seizure management in SAH • seizures in patients with unsecured aneurysms may result in rebleeding, so prophylaxis (typically phenytoin) is commonly given • even a single seizure usually prompts a CT scan to look for a change in the intracranial pathology • additional phenytoin is frequently given to raise the serum concentration to 20+ ug/mL • lorazepam to abort serial seizures or status epilepticus
  36. 36. Nursing management • Altered neurological function related haemorrhage from cerebral aneurysm • Pain due to cerebral haemorrhage • Sensory input distortion related to meningeal irritation • Potential for seizure related to cerebral irritation • Potential for neurological deterioration related to re bleeding or cerebral vasospasm
  37. 37. Complication • Rebleeding • Hydrocephalus • Intraventricular haemorrhage • Increased intracranial pressure • Intracerebral haemorrhage • Seizures • Cerebral vasospasm
  38. 38. COMPLICATIONS • Respiratory complication • Venous complication • Cardiovascular complication • Fluid and electrolyte disturbance • Gastrointestinal complication
  39. 39. Complications with SAH • Vasospasm • Blood vessel goes into spasm causing ischaemia - stroke • To prevent keep them filled with at least 3L fluid day & nimodipine IV/PO & insert central line to monitor central venous pressure – aiming for 8-10 • Suspected with deteriorating GCS/new neurological deficit • Treatment – Urgent CT brain to rule out a bleed as a cause of the deterioration then urgent angiogram to diagnose & treat vasospasm • Greatest risk of vasospasm is days 4-7 but significant risk for first 3 weeks after bleed, therefore must use preventive measures for at least 3 weeks
  40. 40. Complications with SAH • Hyponatraemia • Susceptible due to being fluid loaded & cerebral salt wasting • Cerebral salt wasting = renal loss of sodium due to intracranial pathology ? Cause. Loss of water & salt (whereas SIADH is loss of salt & retention of water) • Treat with normal or hypertonic saline • If refractory may need a mineralocorticoid e.g. fludrocortisone to stimulate renal reabsorption – but this should only be used under instructions from consultant endocrinologist
  41. 41. Complications with SAH • Seizures • A seizure is a disturbance of sensation, movement or consciousness • All seizures originate from the surface of the brain – cortex • Blood is an irritant to the cortex • Prophylaxis with phenytoin or levetiracetam • Ensure phenytoin levels are therapeutic • Treat as seizure from any cause & suspect re-bleed
  42. 42. Complications with SAH • Venous Thrombo Embolism • On bed rest • TEDS (Thrombo Embolism Deterrent Stockings) • Prophylactic enoxaparin as soon as consultant sees fit • Always keep VTE in the back of your mind
  43. 43. Prognosis Hunt and Hess:

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