Management of subarachnoid haemorrhage

Question 1

Describe aneurysm formation

Answer 1

• Haemodynamic stress occurs, normally at the branch of a vessel
• This causes extensive inflammatory and immunological reactions
• If inflammation response attenuates then the aneurysm stabilise but if it continues then the aneurysm will grow and rupture

Question 2

Where do the blood vessels in the brain reside?

Answer 2

In the arachnoid space

Question 3

What can cerebral artery aneurysms cause?

Answer 3

Subarachnoid bleeding

Question 4

What can arteries that penetrate the brain tissue that then rupture cause?

Answer 4

Intracerebral bleeding

Question 5

What happens if a blood vessel ruptures through the Pia?

Answer 5

Parenchymal haemorrhage

Question 6

What happens if a blood vessel ruptures through the arachnoid?

Answer 6

Subdural haemorrhage

Question 7

What is aneurysmal subarachnoid haemorrhage?

Answer 7

•Acute cerebrovascular event

Question 8

What are the predisposing factors of an aneurysmal subarachnoid haemorrhage?

Answer 8

• Smoking
• Female
• Hypertension
• Family history
• ADPCK, Ehlers Danlos, corctation of the aorta

Question 9

what is the classical presentation of an aneurysmal subarachnoid haemorrhage?

Answer 9

• Acute headache with a sudden onset
• loss of consciousness, seizure, visual(ophthalmic)/speech(MCA) /limb disturbance (anterior communicating)
• Sentinel headache

Question 10

What are the clinical signs of aneurysmal subarachnoid haemorrhage?

Answer 10

• Photophobia
• Meningism (neck stiffness due to the irritation of the meninges by blood)
• Subhyaloid haemorrhage
• Vitreous haemorrhage (red reflex lost) - terson syndrome
• Speech/limb disturbance
• Cardiovascular problems (e.g. pulmonary oedema)

Question 11

Describe the appearance of subhyloid haemorrhage

Answer 11

• Collection of blood, fills kind of like a cup

* Between the vitreous and the retina

Question 12

Explain the grading system of subarachnoid haemorrhage

Answer 12

• WFNS Grades
• GCS 15 = grade I
• GCS 13-14 with no deficit = grade II
• GCS with deficit = grade III
• GCS 7-12 = Grade IV
• GCS 3-6 = Grade V

Question 13

What investigations should you carry out in suspected aneurysmal subarachnoid haemorrhage?

Answer 13

• CT to confirm diagnosis and give clues to aetiology/assess complications/prognositc
• FBC, UEs, LFT, glucose, troponin
• ECG
• CTA/MRA/DSA
• Echocardiogrpahy - tako tsubo cardiomyopathy

Question 14

If a CT scan is negative in suspected SAH, what should you do?

Answer 14

Lumbar puncture to look for oxy haemoglobin vs bilirubin

Question 15

What are the cautions of a CTA?

Answer 15

eGFR

Question 16

What are the cautions for a MRA?

Answer 16

• eGFR

* Gadolinium

Question 17

What are the cautions of DSA?

Answer 17

• Diabetes

* Also there is a risk of stroke

Question 18

Explain resuscitation in patients with SAH

Answer 18

• Bed rest
• Fluis: 2.5-3 litres of normal saline
• Anti-embolic stockings
• Nimodipine
• analgesia
• Doppler studies

Question 19

What is the role of nimodipine in SAH?

Answer 19

Inhibits calcium dumping, preventing late ischaemia deficit

Question 20

What are the management options in SAH?

Answer 20

• Endovascualr (coils and others)
• Surgical clipping
• Conservative - very few

Question 21

How can you check that you have successfully clipped an aneurysm?

Answer 21

Puncture it to ensure it isn’t filling

Question 22

Describe medicine therapy after stent assisted coiling

Answer 22

• Use of anti platelet agents
• Clopidogrel for 3 months
• ASA for life (acetylsalicylic acid)

Question 23

What are the complications of a SAH?

Answer 23

• Rehaemorrhage
• Delayed ischaemia
• Hydrocephalus
• Hyponatraemia
• Cardiovascular problems
• LTRI, DVT/PE, UTI

Question 24

When is the risk of rehaemorrhage in SAH high?

Answer 24

• Incidence is highest immediately following the initial bleed
• 5-10% over 1st 72 hours
• higher in poorer grade patients
• Higher risk in larger aneurysms

Question 25

Describe the treatment and morbidity of rehaemorrhage

Answer 25

*  Immediate repair reduced the rebreeding risk *  Antifibrinolytic therapy reduces rebleeding but no benefit on poor outcome die to significantly higher incidence of cerebral ischaemia

Question 26

What is the management of hydrocephalus?

Answer 26

*  LP and EVD insertion to relieve *  If prolonged and repeated LPs are needed then shunt *  Some will just resolve by themselves

Question 27

What causes hydrocephalus in SAH?

Answer 27

Inflammation/irrittion at the arachnoid granule level

Question 28

When is delayed ischaemia likely to happen after SAH?

Answer 28

*  Day 3-10 | *  Peak on day 7

Question 29

What are the signs of delayed ischaemia after SAH?

Answer 29

*  Progressive deterioration in level of consciousness associated with new deficit *  Angiographic spasm

Question 30

What is the management of delayed ischaemia following SAH?

Answer 30

*  fluid management *  Nimodipine *  Inotropes *  Angioplasty

Question 31

Describe the management of hyponatraemia following SAH

Answer 31

*  Cerebral salt wasting vs SIADH *  Establish the volume status *  Hypertonic saline *  fludrocortisone

Question 32

What are the cardiopulmonary complications of SAH?

Answer 32

*  Sympathetic stimulation and catecholamine release can lead to myocardial surgery *  Arrhythmia is 35% *  wall motion abnormalities *  Sudden death can occur *  Myocardial function usually returns to normal in 1-3 days

Question 33

What are seizures post SAH often a manifestation of?

Answer 33

Re-rupture

Question 34

Explain DVT prophylaxis post SAH

Answer 34

*  SAH induces a prothrombotic state *  DVT in SAH in 2-18% *  Higher in poor grade *  Safer to use sequential compression devices initially then LWMH after the aneurysm is secured *  Withold LMWH 24 hours before and after intracranial procedures