Subarachnoid Hemorrhage and It’s Complications Diana Greene-Chandos, M.D. Director of Neuroscience Critical Care Assistant Professor of Neurosurgery and Neurology The Ohio State University Wexner Medical Center
Jan 13, 2016
Subarachnoid Hemorrhage and It’s Complications
Diana Greene-Chandos, M.D.Director of Neuroscience Critical CareAssistant Professor of Neurosurgery and NeurologyThe Ohio State University Wexner Medical Center
Objectives
Describe the underlying pathology and symptoms of subarachnoid and hemorrhagic stroke
Identify risk factors associated with spontaneous intracerebral hemorrhage.
Describe the factors associated with hematoma expansion and poor outcome.
Understand the role and indications for surgical hematoma evacuation. Identify when additional imaging is needed after intracerebral
hemorrhage. Define stroke and understand its natural history Discuss the risk factors and pathogenesis of vascular disease
The Subarachnoid Space
The interval between the arachnoid membrane and pia mater.
More generous in the spine
Or It’s a Great Name for a Band
Bleeding in the Subarachnoid Space
Trauma (most common etiology) Aneurysmal Benign perimesencephalic
Traumatic SAH
Traumatic SAH
Tends to happen more commonly with moderate to severe head trauma
Typically associated with other types of brain injury such as contusions, subdural hematomas and/or diffuse axonal injury
Typically associated with additional body or head and neck trauma.
Low risk of delayed ischemic deficits but can have cerebral salt wasting syndrome
Aneurysmal SAH
5% of population Rupturing is more common in women overall and in men
under the age of 40
Overall Aneurysmal SAH Prognosis Among 100 typical patients with a-SAH
33 will die before receiving medical care 20 will die or remain incapacitated from initial SAH 17 will deteriorate (50% recovering and 50% with severe
neurological deficits) 30 will do well
Cerebral Aneurysms
Most common sites for cerebral aneurysms
Other tidbits about aneurysms
Multiple aneurysms present 14-24% of the time 7-20% of of pts with a ruptured aneurysm have a
first or second degree relative with an aneurysm If you are a first degree relative of someone with
a ruptured cerebral aneurysm risk of having an aneurysm is 4 times higher
Screening should occur in people with 2 or more first degree relatives with cerebral aneurysms or with 1 relative and tobacco abuse history +/- uncontrolled hypertension.
Risks for cerebral aneurysm formation Hypertension Tobacco abuse Polycystic Kidney Disease Coarctation of the Aorta Fibromuscular Dysplasia Pseudoxanthoma Elasticum Marfan’s syndrome
Risks for cerebral aneurysm rupture
Surges in blood pressure Strenuous activity Size greater than 7mm
The symptoms..
Sudden severe headache Usually occipital Nuchal pain also present Vomiting Decreased alertness
Sentinel Hemorrhage
31% of patients have a sentinel headache 50% of patients with a sentinel hemorrhage are
misdiagnosed by physicians.
Focal Neurological Deficits with Cerebral Aneurysms
Bitemporal Hemianopsia Basilar bifurcation
Weber’s Syndrome Giant SCA
Hemiparesis and Aphasia or Sensory Neglect Giant MCA Aneurysms
Third Nerve Palsy (Pupil involved): Intracranial ICA PCOM SCA
Diagnosis of Aneurysmal SAH
Head CT is BEST…. Do not hesitate to do an LP if there is any doubt…collect
Tube #1 and Tube #4 for cell count with differential Note: it may take up to 12 hours after onset of HA for
xanthrochromia to develop if just color is being looked at Spectrophotometry will quantify the amount of
hemoglobin and bilirubin and is independent of age of SAH.
CT example of Aneurysmal SAH
The Fisher Grade
I.....No blood evident on CT II….Blood less than 1mm at maximal width on CT III….Blood greater than 1mm maximal width on CT IV….Any blood width with IVH or parenchymal extension
The Hunt-Hess Grade
I…..Asymptomatic or Minimal HA and slight nuchal rigidity
II….Moderate to Severe HA, nuchal rigidity, no neurological deficit other than CN
III….Drowsiness, confusion or mild focal deficit
IV….Stupor, moderate to severe hemiparesis V….Deep coma with posturing
You’ve confirmed SAH…now what?
Admit to NCCU…no matter what. Keep the patient calm, quiet and pain free. SBP must be kept below 160 systolically Minimize procedures Best drugs for bp
Labetolol 10-20mg iv q 15 min prn Hydralazine 10 mg iv q 20 min prn If 3 doses required within 2 hours start Nicardipine
drip at 5mg/hr and titrate to goal bp
Confirmation of an Aneurysm
• CT angiography will help the angiographer know where to focus (but avoid if there is clear SAH and significant renal dysfunction in a patient NOT on HD)
• Cerebral Angiography is the gold standard.• If the aneurysm is able to be coiled intravascularly, it will
be done at the time of the angiogram.
Example of CT with Corresponding Angiography
The coiling process with microcatheter
What if it cannot be coiled?
The Titanium Clip!
The Pipeline Stent
Back to the NCCU…what’s next?
Cerebral Edema Phase Days 3-5 post SAH Utilize Hypertonic (3%) Saline to decrease Why not Mannitol?
The Vasospasm Window
Days 4-14 Creates Delayed Ischemic Deficits Responsible for worsening outcomes in 1/3 patients
Monitoring Vasospasm Clinical Symptoms (HA, confusion, focal deficits) Clinical Signs (increasing bp, increasing urinary output,
dropping sodium levels) Studies:
Transcranial Doppler CT Angiography (95% negative predictive value) CT Perfusion Cerebral Angiography EEG with Compressed Spectral Analysis
Preventing (?) Vasospam
Nimodipine 60mg p.o. q 4 hrs for 21 days Euvolemia Normal Magnesium level (2.0 or greater) Avoid hypotension Treat abnormal LDL with statins
Treating Vasospasm (Medical)
• HHH therapy (Hypervolemia, Hypertension, and Hypoviscosity)
• Goal Intake and Output net for every 24 hours should be 1-500cc positive
• Goal SBP 160-220 (may use neosynephrine once a clear euvolemia to slightly hypervolemic state is reached to achieve)
• Goal Hemoglobin is 10
Treating Vasospasm (Surgical)
Intra-arterial injection of Calcium Channel Blockers (here we use verapamil) at the site of vasospasm
Direct Angioplasty (high risk)
What about AEDs?
Use in all aneurysmal SAH until aneurysm secure. If a seizure has occurred, keep AED for 4 weeks If a seizure has occurred and an intraparenchymal
hemorrhage was also present, consider longer treatment than 4 weeks.
Leviteracetam or Phenytoin
What About Hydrocephalus?
Common EVD should be placed in those with radiographic HCP
and high grade SAH Delayed Hydrocephalus (under normal pressure) can
occurred months or even years after SAH due to scarring
What if there is an SAH and a Negative Angiogram? Re-review history….? Occult trauma Thrombosis of ruptured aneurysm Difficult to visualize small aneurysm Spinal AVM Cerebral Venous Thrombosis Vasculitis Benign Perimesencephalic
Negative-Angiogram SAH Words to Never Forget…..
Remember: The Onus is on us to prove that there is no aneurysm. So if one is not seen on the first angiogram and there is no other etiology for the hemorrhage found, repeat the angiogram in 7 days.
Cardiac Effects
Catecholamine induced subendocardial myonecrosis Temporary or permanent reduction in EF Arrythmias (typically tachyarrhythmia unless increased
ICP, then bradyarrhythmias) Flash pulmonary edema
Monitoring and Care
Ideally in a high volume center Institutions with a dedicated Neuro-ICU with
Neuroscience Nurses are preferred and shown to improve outcomes
My reasons to prevent a Stroke
Subarachnoid Hemorrhage Quiz
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