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Acute Care I > Neuro Emergencies: SAH > Flashcards

Neuro Emergencies: SAH Flashcards

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1
Q

A SAH is bleeding that occurs where?

A

between the pia on the surface of the brain, and the arachnoid layers of the meninges

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2
Q

Risk Factors for SAH include

A

Cigarette smoking
HTN
ETOH
Genetic risk
Estrogen deficiency
Sympathomimetic drugs
Coagulopathy

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3
Q

Genetic risk factors for SAH include

A

Connective tissue d/o
Familial occurrence (In individuals w/ >/= two 1* relatives w/ known cerebral aneurysms, there is a 12% prevalence of harboring a cerebral aneurysm)
Autosomal dominant polycystic kidney disease
Marfan Syndrome
Ehlers-Danlos Syndrome

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4
Q

Causes of Subarachnoid Hemorrhages

A

Intracranial aneurysms
Trauma
Vascular malformations
Arterial dissection

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5
Q

Types of Intracranial Aneurysms

A

Saccular
Mycotic
Fusiform

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6
Q

Clinical Manifestations of SAH

A

Sudden severe headache (can have sentinel headache)
Altered LOC
Seizure
N/V
Meningisums
Cranial Nerve palsy
Focal neurological deficit
Normal exam
Coma

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7
Q

Systemic Complications After SAH
Early brain injury after aneurysm rupture includes

A

Elevated ICP w/ decreased CPP
Small and large artery constriction and thrombosis
Impaired autoregulation
Inflammation w/ cell death by necrosis and apoptosis
Cerebral edema
Blood-brain barrier disruption

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8
Q

Systemic Complications After SAH
Other

A

ECG changes
Myocardial stunning
Neurogenic pulmonary edema
SIRS

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9
Q

Care continuum of the patient w/ aSAH
Early Brain Injury requires?

A

Acute resuscitation
Emergency dx
Prevent rebleeding
treat hydrocephalus
manage elevated ICP
Manage seizures

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10
Q

Care continuum of the patient w/ aSAH
Delayed Brain Injury can include?

A

Delayed cerebral ischemia
Sodium dysregulation
systemic complications
fever and temp management
glucose management
nutritional support

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11
Q

Care continuum of the patient w/ aSAH
Recovery should include?

A

Acute rehab
HA and Seizure management
Mnitoring of aneurysms
screening for cognitive and mood d/o’s
long-term outcomes

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12
Q

Diagnosis Imaging

A

Head CT (99% sensitive and specific w/n 6h of symptom onset)
CTA
Digital Subtraction Angiography (DSA)

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13
Q

What is the Gold standard for evaluation of cerebrovascular anatomy and aneurysm geometry and can aid in decision making on the choice of optimal treatment modality?

A

Digital subtraction angiography (DSA)

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14
Q

Diagnosis Lab Studies?

A

BMP
PT/INR, PTT
CBC
troponin
Type and Screen
UDS
HCG (if appropriate)

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15
Q

Diagnosis bedside studies?

A

ECG
+/- CXR

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16
Q

When is a Lumbar Puncture indicated?
Sensitivity?

A

When clinical suspicion of aSAH is high and head CT is negative
99% sensitive when performed 12 hrs after symptom onset

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17
Q

SAH Grading System
Hunt and Hess Classification of SAH
Grade 1 =?

A

Asymptomatic, or minimal HA; slight nuchal rigidity

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18
Q

SAH Grading System
Hunt and Hess Classification of SAH
Grade 2 =?

A

Moderate to severe HA, nuchal rigidity; no neuro deficits (apart from cranial nerve palsy)

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19
Q

SAH Grading System
Hunt and Hess Classification of SAH
Grade 3 =?

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A

Drowsiness, confusion, or mild focal deficit

20
Q

SAH Grading System
Hunt and Hess Classification of SAH
Grade 4 =?

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A

Stupor, moderate to severe hemiparesis; possible early decerebrate posturing

21
Q

SAH Grading System
Hunt and Hess Classification of SAH
Grade 5 =?

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A

Deep coma, decerebrate posturing, moribund

22
Q

SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade I
GCS score?
Motor Deficit?

23
Q

SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade II
GCS score?
Motor Deficit?

24
Q

SAH Grading System
World Federation of Neurological Surgeons Scale
WFNS Grade III
GCS score?
Motor Deficit?

25
SAH Grading System World Federation of Neurological Surgeons Scale WFNS Grade IV GCS score? Motor Deficit?
12-7 present or absent
26
SAH Grading System World Federation of Neurological Surgeons Scale WFNS Grade V GCS score? Motor Deficit?
6-3 present or absent
27
SAH Grading System Modified Fischer Scale is based on what?
Head CT results
28
SAH Management ABC considerations? BP control until when? Goal? Reversal of? Activity orders? Antifibrinolytics usefulness? What to do with hydrocephalus?
May need intubation; arrhythmias are common aneurysm obliteration; Maintain SBP < 160 or MAP < 110 Anticoagulnts Bed rest Routine use of antifibrinolytic therapy is not useful to improve functional outcomes Treat hydrocephalus (consider osmotic therapy)
29
SAH Management First line of vasospasm prevention administer what? dose? frequency?
Nimodipine 60mg q4 hrs
30
SAH Management Consider surgical intervention to evacuate what?
hematoma
31
SAH Management Antiepileptic medications should be given to patients with? (4) What to administer? dose? frequency? duration?
MCA aneurysm high clinical/radiological grade (HH grade >3, fisher grade III/IV) cortical infarction hydrocephalus has been associated w/ an elevated seizure risk Levetiracetam 500mg BID x 3 days
32
Hydrocephalus Management CSF fluid diversion can be accomplished with?
EVD Lumbar drain
33
Surgical management includes?
Surgical clipping
34
Endovascular management includes
endovascular coiling Endovascular stent
35
Post treatment imaging In pts w/ aSAH who have undergone aneurysm repair, perioperative cerebrovascular imaging is recommended to identify what?
remnants or recurrence of the aneurysm
36
Vasospasm Related to a number of pathological processes which are?
Endothelial damage and smooth muscle cell contraction resulting from spasmogenic substances generated during lysis of subarachnoid blood clots Changes in vascular responsiveness Inflammatory or immunological reactions of the vascular wall
37
Vasospasm Typical onset occurs when? Peaks when? Resolves by day? Major source of what? Accounts for what % of death in pts surviving treatment after SAH?
4-5 days 4-10 days 21 delayed cerebral ischemia (DCI) nearly 50%
38
Clinical Manifestations of Vasospasm include?
Focal neurological deficits Global Neurological Changes Nonspecific findings
39
Clinical Manifestations of Vasospasm Focal Neurological deficits such as?
Hemiparesis Aphasias
40
Clinical Manifestations of Vasospasm Global Neurological Changes such as?
Confusion or agitation stupor or coma
41
Clinical Manifestations of Vasospasm Nonspecific findings such as?
Fever HA Hyponatremia
42
Vasospasm Diagnosis can be accomplished with?
Clinical diagnosis cerebral angiography CT angio or CT perfusion cEEG
43
Treatment of Vasospasm includes
Blood pressure augmentation Euvolemia Balloon Angioplasty Endovascular vasodilators Transcranial Dopplers
44
Which method of treatment for vasospasm is no longer used?
Triple H therapy 1. HTN 2. Hemodilution 3. Hypervolemia
45
SAH Management includes?
Neurological monitoring No hypotonic fluids Aggressive fever control Glucose management VTE prophylaxis (LMWH 40 mg vs Heparing 5000 u BID or TID) Blood transfusion to treat anemia Correction of Hyponatremia (Hypertonic Saline, Fludrocortisone 0.1mg TID) Dysphagia Screening Early mobilization w/n the 1st 4 days after aneurysm is secured
46
Hyponatremia in SAH - SIADH Serum Osmolality Urine Osmolality BUN HR CVP Treatment
low/normal high normal normal normal Avoid excess PO fluids; conivaptan
47
Hyponatremia in SAH - CSW Serum Osmolality Urine Osmolality BUN HR CVP Treatment
Normal/high high rising tachycardia low isotonic or hypertonic saline

Acute Care I (30 decks)

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