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FRCS Part 1 > Ch74 Subarachnoid haemorrhage > Flashcards

Ch74 Subarachnoid haemorrhage Flashcards

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1
Q

What is the most common cause of SAH?

A

Trauma

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2
Q

What is the peak age for SAH?

A

55-60 years

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3
Q

Which aneurysms cause subdural haemorrhages?

A

pCom and distal ACA (interhemispheric subdural)

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4
Q

What are the medical complications of SAH that cuase immediate mortality?

A

Neurogenic pulmonary oedema Myocardial stunning Arrhythmias (VF)

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5
Q

What is the rebleeding risk?

A

14% by 2 weeks

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6
Q

What is the strongest prognostic indicator of outcome following SAH?

A

Severity of clinical presentation

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7
Q

Is SAH more common in men or women?

A

Women (1.24:1)

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8
Q

What are the risk factors for aneurysmal SAH?

A

Mnemonic: Genetic CASH Family history (1 first deg relative) Polycystic kidney disease (autosomal dominant) Ehlers-Danlos syndrome type 4 Cocaine Alcohol abuse Smoking Hypertension

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9
Q

What is the differential for a severe sudden onset headache?

A

SAH Benign thunderclap headache (a type of migraine) Reversible cerebral vasoconstrictive syndrome (a string of beads appearance on angiography that resolves by 3 months). Associated with vasoconstrictive substances Benign orgasmic cephlagia

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10
Q

What at Kernig’s and Brudzinski signs?

A

Kernig = flex thigh to 90 and straighten knee causing pain in Hamstring’s Brudzinzki = flex patients neck and the hip flexes

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11
Q

What are the causes of coma following SAH?

A

Seizure Hydrocephalus Raised ICP Brain damage Diffuse ischaemia

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12
Q

What ocular haemorrhages occur following SAH?

A

Subhyaloid (pre-retinal) - has a fluid level

Intraretinal - flame shaped

Vitreous humor (Terson’s syndrome) - usually bilateral and appears after a few days.

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13
Q

What is the longterm prognosis for vision after Terson’s syndrome?

A

Most resolve spontaneously in 6-12 months Longterm visual prognosis is 80%

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14
Q

What is the diagnostic sensitivity of CT for SAH?

A

95% @ 2 days

50% @ 7 days

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15
Q

Which aneurysms cause blood in the sylvan fissure?

A

MCA and PCom

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16
Q

Which aneurysms cause blood in the prepontine cistern?

A

Basilar tip and SCA

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17
Q

Which aneurysms cause blood in the 4th ventricle?

A

PICA and vertebral A

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18
Q

Which aneurysms cause blood in the 3rd ventricle?

A

Basilar tip

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19
Q

What are the LP findings with SAH?

A

High opening pressure

No clotting bloody fluid that does not reduce with sequential tubes (take 3 samples)

Xanthochromia with spectrophotometry (sample should be shielded from light)

Cell count >100,000 rbc

Elevated protein

Normal or low glucose

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20
Q

When should the LP be performed for CT negative SAH?

A

After 12 hours so xanthochromia can be formed (note: false positives with jaundice)

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21
Q

When does MRI become sensitive for SAH?

A

>4-7 days once enough met-Hb is present

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22
Q

Which MRI sequence is most sensitive for detecting SAH blood?

23
Q

How sensitive is MRA compared to DSA for aneurysm detection?

Study These Flashcards
A

90%. Poor sensitivity for aneurysms <3 mm.

24
Q

What is the sensitivity of CTA compared to DSA?

25
What are the general principles of performing a DSA in SAH?
Study the vessel with greatest suspicion 4 vessel angio Visualise both PICA origins Visualise flow across the ACom - may need cross compression test
26
What are the criteria for an infundibulum?
\<3mm Vessel at the apex Triangular shape
27
What factors should be considered when deciding clip v coil for an aneurysm?
Narrow (\< 5mm) good for coiling Broad (\>5 mm) bad for coiling due to coil prolapse and recanalisation Dome to neck ration \>2 good for coiling Presence of branches or perforators that may be occluded with coiling
28
What is the Hunt and Hess grading scale for SAH?
Described in 1968: 1 - Asymptomatic 2 - Headache or CN palsy 3 - Confusion 4 - Stupor / decerebrate / hemiparesis 5 - Deep coma Add one for severe comorbidities or severe vasospasm. Modified version has 0 for unruptured aneurysm.
29
What are the mortality rates associated with H&H grade 1/2?
20%
30
What is the WFNS SAH grade?
1 = GCS15 2 = GCS13/14 no deficit 3 = GCS13/14 with deficit 4 = GCS 7-12 5 = GCS 3-6
31
What is the incidence of SAH during pregnancy?
1 in 10,000, but represents 10% of maternal deaths. Maternal mortality with SAH = 30%!
32
How do you manage SAH in pregnancy?
Immediate surgical treatment reduced maternal mortality from 63% to 11 and fetal mortality from 27% to 5%. Fetal radiation exposure is a concern with coiling.
33
What is the risk of hydrocephalus following SAH?
20-30%. Increased risk in elderly, large ventricular blood volume and posterior circulation aneurysms
34
What % of poor grade SAH patients and hydrocephalus improve with CSF diversion?
80%. Keep the EVD at 15 to prevent rebleed
35
What is the risk of vasospasm with modified Fisher grading system?
1 = Thin SAH no IVH = 24% 2 = Thin SAH with IVH = 33% 3 = Thick SAH no IVH = 33% 4 = Thick SAH with IVH = 40%
36
What are the pathological changes the occur with vasospam?
Day 1-8 = increase in inflammatory cells in the adventitia and connective tissues, muscle necrosis and corrugation of elastin in tunica media and endothelial thickening with opening of tight junctions in the intima. Day 9-60 - progressive smooth muscle proliferation in the intima causing intimal thickening
37
Why does blood contact with vessels cause vasospasm?
OxyHb causing muscle contraction Hb scavenges nitric oxide preventing wall dilation PDGF induces proliferation and impairs dilation Overproduction of Endothelin-1
38
How do you diagnose vasospasm?
Delayed onset of neurological deficit 4-20 days post ictus Deficit in the territory of the spastic arteries Other causes of neurological decline (rebleed, hydrocephalus, cerebral oedema, seizure, hypoNa, hypoxia and sepsis) ruled out TCD (Lindegaard ratio)
39
What EEG feature predicts the onset of clinical vasospasm?
Reduction in the % alpha activity (relative alpha) falls.
40
What tests can be done to confirm the presence of vasospasm?
TCDs CTA and CT perfusion DSA
41
What is the Lindegaard ratio?
Insonate the ICA and MCA. If the ratio: MCA:ICA \< 3 = normal MCA:ICA 3-6 = mild MCA:ICA \>6 = severe \*\*only 60% sensitive
42
How can you treat vasospasm?
Prophylactic Nimodipine Hypertense (most important part of triple H) - need A-line and pressors Angioplasty (mechanical or chemical with verapamil / nimodpine) CSF drainage
43
What are the risks associated with Triple-H therapy?
Pulmonary oedema MI Rebleed
44
Which grading system is a predictor of vasospasm?
Modified Fisher (not Fisher) once you adjust for hypertension, neurological grade and high MAP which are independent predictors themselves. Modified fisher: 1 = Focal or diffuse thin no IVH 2 = Focal or diffuse thin with IVH OR 1.6 3 = Focal or diffuse thick no IVH OR 1.6 4 = Focal or diffuse think with IVH OR 2.2
45
What drug should moya moya patients be given lifelong?
Aspirin!
46
What is the angiographic staging system for moya moya?
Suzuki staging 1- stenosis of ICP 2- development of moya moya vessels at base of brain 3- Increasing stenosis and prominance of vessels 4- Entire circle of willis occluded 5 - further progression 6 - Complete absence of major cerebral arteries and moya moya vessels
47
What are the secondary causes of moya moya?
Atherosclerosis, autoimmune, meningitis, downs, NF-1, radiotherapy, sickle cell disease etc
48
What imaging modality is needed to diagnose moya moya?
Unilateral - needs DSA Bilateral - can be diagnosed on MRA
49
What is the watershed shift phenomenon in moya moya?
Where the retrograde blood supply from the STA-MCA interferes with the antegrade supply from the MCA resulting in a decrease in CBF at the cortex in adjacent regions. More common in paediatrics than adults.
50
What is cerebral hyperperfusion in moya moya?
After direct STA-MCA bypass at day 2-6, the increase in CBF causes a haemorrhage. Seen in 40% of adult moya moya cases.
51
What is the optimal stroke management?
Thrombolysis and if unsuccessful within 30 mins proceed to mechanical thrombectomy (Trials = MRCLEAN, EXTEND 1A, ESCAPE, SWIFT PRIME and REVASCAT). Combined thrombolysis + thrombectomy doubles odds of favourable outcome compared to thrombolysis alone.
52
What does the ASPECT score tell you?
Used to score how widespread strokes are. 1 point is reduced with every vascular territory involved. Scores \<7 are associated with a worse functional outcome at 3 months.
53
How would you treat a patient \>70 years with a symptomatic carotid stenosis?
Endarterectomy safer than carotid stenting in older patients. Associated with higher risk of stroke and death but lower risk of MI.

FRCS Part 1 (85 decks)

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