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SAH oman fanja sult
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Background
Etiology of SAH
Risk factors of SAH
Diagnostic investigations
Management of SAH in ED
Disposition
Complication of SAH
A 60 year old male k/c/o HTN presented to the emergency department complaining of a sudden, acute onset headache “worst headache of my life “ that radiated into his neck. Symptoms began three hours
prior to presentation and were associated with nausea and vomiting.
Subarachnoid hemorrhage (SAH) is a pathologic condition that exists when blood enters the subarachnoid space
SAH
traumatic Non traumatic
Aneurismal
85%
Non aneurismal
15%
perimesencephalichemorrhage
50%
Other disorders
CATEGORY CAUSES
TRAUMA CLOSED, PENETRATING, ELECTRIC,ETC…
VASCULAR ANEURYSMS, ATHEROSCLEROSIS, AVM, VASCULITIDES
IDIOPATHIC BENIGN PERIMESENCEPHAIC SUBARACHNOID
HEMORRHAGE
BLOOD DYSCRASIAS LEUKEMIAS, HEMOPHILIAS, THROMBOCYTOPENIAS
INFECTIONS DENGUE, LEPTOSPIROSIS, BACTERIAL MENINGITIS
TOXINS AMPHETAMINES, COCAINE, NICOTINE,
ANTICOAGULANTS
NEOPLASMS GLIOMAS, MENINGIOMAS, HEMANGIOBLASTOMA, ETC
Incidence about 9-10/100,000/yr
Higher in Japan (3 times) and Finland
Mean age of onset 51 years (6th decade)
Facts and figuresMen predominate until age 40, then more women (55%); some studies – 3:2 ratio
30 % rupture during sleep??
About 50 % of patients with an aneurysm have warning prior to SAH (6-20 days).
Average case fatality rate for SAH was 51 %
Population-based study in England with essentially
complete case ascertainment
24 hour mortality: 25%
7 days: 37%
30 days: 45%
Pobereskin JNNP 2001;70:340-3
Hypertension
Cigarette smoking
Oral contraceptives
Alcohol consumption
Diurnal variations in blood pressure
Pregnancy and parturition
Slight increased risk with advancing age
Following cocaine abuse
Headache:Features: Sudden and severe "worst headache of my life“
Associated Symptoms: brief loss of consciousness (coma is unusual) 57%
nausea or vomiting 77%
meningismus 35%??
Seizure <10% poor prognostic indicator
CT Scan :
Within 6-12 hr sensitivity 100% (Perry JJ ,et al, 2011)
CT sensitivity progressively declines over time to about 58% at day five.
Lumbar Puncture:
LP is mandatory if strong suspicion of SAH despite negative CT
Negative CT and LP effectively eliminate the diagnosis of SAH
Follow-up LP unnecessary , If CT scan preformed within 6 hr.
Findings: elevated opening pressure and an elevated RBC count in all
tubes, Xanthochromia
MRI:
Less sensitive than CT scan in diagnosing acute SAH
FLAIR and T2 have a high sensitivity in patients with a
sub-acute presentation of SAH
If there is a large amount of SAH particularly in the basal cisterns, sulci & fissures the physician should consider a ruptured aneurysm
Traumatic SAH occurs most commonly over the cerebral convexities or adjacent to otherwise injured brain (i.e. adjacent to a cerebral contusion)
Angiography:To determine the etiology of hemorrhage
DSA
MRA /CTA
CTA/MRAConventional angiography
•noninvasive tests•screening and pre-surgical planning•identify aneurysms 3 to 5 mm or larger
•Less resolution than conventional Angiography •Less sensitive
-Better resolution-High sensitivity in detecting aneurysm
-invasive
GRADE SIGNS/SYMPTOMS SURVIVAL
1 Asymptomatic/Minimal headache or neck stiffness
70%
2 Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy
60%
3 Drowsy/ minimal neurological deficit 50%
4 Stuporous with hemeparesis 20%
5 Comatose with decereberateposturing/response
10%
HUNT AND HESS IN 1968
GRADE GCS NEURODEFICIT
1 15 ABSENT
2 13-14 ABSENT
3 13-14 PRESENT
4 7-12 ABSENT/PRESENT
5 <7 ABSENT/PRESENT
WORLD FEDERATION OF NEUROSURGEONS (WFNS)
GRADE CT APPEARANCE
1 No blood detected
2 Diffuse deposition or thin layer with all vertical layers (in interhemispheric fissure, insular cistern, ambient cistern) less than 1 mm thick
3 Localized clot and/or vertical layers 1 mm or more in thickness
4 Intracerebral or intraventricular clot with diffuse or no subarachnoid blood
FISHERS
GRADE CT APPEARANCE
0 No SAH or IVH
1 Minimal SAH and no IVH
2 Minimal SAH with bilateral IVH
3 Thick SAH (completely filling one or more cistern or fissure) without bilateral IVH
4 Thick SAH (completely filling one or more cistern or fissure) with bilateral IVH
CLAASSENS MODIFICATION
ABC
Triage and transport patients with ALC or an abnormal neurologic examination to the closest medical center with a CT scan and neurosurgical backup.
ABCIntubation.Acute medical care:
Control BP (decrease risk of Rebleeding): sBP<160 or mean arterial BP <110Use Labetalol, nicardipine
DVT prophylaxis :pneumatic compression stockings.unfractionated heparin 5000 units TID can be added.
IV fluid analgesia kept at bed rest
Nimodipine {CCB} (60mg PO or NGT every 6hr) reduce incidence and severity of Vasospasm.
Antifibrinolytic agents (eg, tranexamic acid)Reduce risk of re-bleeding
Antiepileptic drug therapy and steroids: controversial
Statins: unknown mechanism but advisable
ICU bed
Neurosurgeon & neuroradiologist consultation: for surgical clipping or endovascular coiling
Nonaneurysmal SAH generally has a more benign course, so angiographic intervention is not typically undertaken in these cases.
Re-bleeding:8 to 23 %highest in the first 24 hoursManifestation : acute deterioration of neurologic status accompanied by appearance of new hemorrhage on CT scanAneurismal Rx is best way to prevent re-bleeding.
Vasospasm and Delayed cerebral Ischemia:40 to 60 %Late presentation: >3 daysManifestation: neurologic deterioration in LOCor new focal neurologic deficits
Hydrocephalus:15% of pt with SAH75% of pt resolve spontaneously
SeizureHyponatremia
Cardiac abnormalities:ECG changes:
ST segment depression, QT interval prolongation, deep symmetric T wave inversions, and prominent U waves
Left ventricular dysfunctionElevated trop I levelElevated BNP
http://ezproxy.squ.edu.om:2983/contents/clinical-manifestations-and-diagnosis-of-aneurysmal-subarachnoid-hemorrhage?source=search_result&search=subarachnoid+hemorrhage&selectedTitle=1~150
http://ezproxy.squ.edu.om:2983/contents/treatment-of-aneurysmal-subarachnoid-hemorrhage?source=see_link&anchor=H259178626
http://www.bmj.com/content/343/bmj.d4277
http://stroke.ahajournals.org/content/40/3/994.full#sec-9
http://emedicine.medscape.com/article/794076-overview#aw2aab6b4
http://www.medscape.com/viewarticle/803838_3