SAH

Question 1

What are the sensitivities of CT in thunderclap headache at 6 and 12 hrs and 5 days?

Answer 1

6hrs: 98-100%
12 hrs: 86-98%
6 days: 60%

Question 2

What may help to predict the site of the rupture of an aneurysm?

Answer 2

A non-contrast CT

Particularly involving the anterior cerebral artery and anterior communicating artery.

Question 3

What percentage of patients with SAH have another aneurysm in addition to the one that ruptured?

Answer 3

20%

Identifying another aneurysm is important for intervention.

Question 4

What is pathognomonic in the absence of trauma?

Answer 4

Subhyaloid haemorrhage

This is seen only in <25% of patients presenting with SAH.

Question 5

Does SAH present with syncope as a sole symptom?

Answer 5

No

There are usually associated symptoms, mainly headache.

Question 6

What is the sensitivity of non-contrast CT in detecting subarachnoid blood when performed within 12 hours of symptom onset?

Answer 6

Up to 98%

MRI is not as sensitive as non-contrast CT in detecting acute blood in the brain.

Question 7

What does a reducing number of RBCs in CSF tubes 1-4 indicate?

Answer 7

Possible traumatic tap

This has not been proven definitively.

Question 8

What percentage reduction in RBC count in successive tubes could occur in patients with a traumatic tap?

Answer 8

25%

A reducing RBC count should be interpreted with caution as this can be HAPPEN IN SAH AS WELL

Question 9

How quickly can xanthochromia from a traumatic tap develop?

Answer 9

As early as 2 hours

Xanthochromia from SAH may take 6-12 hours to develop.

Question 10

What causes xanthochromia?

Answer 10

Presence of bilirubin

Bilirubin degradation can occur when a CSF sample is exposed to light.

Question 11

What does a negative predictive value indicate regarding CT and xanthochromia?

Answer 11

Excludes SAH

When CT is normal, negative xanthochromia, and up to a few RBCs (0-5) reliably excludes SAH.

Question 12

Is there adequate evidence to suggest the use of CTA as a first-line investigation for SAH?

Answer 12

No

There are only a few studies comparing CTA with non-contrast CT and LP.

Question 13

What percentage risk of rupture is found in patients with an unruptured aneurysm and symptomatic headache?

Answer 13

8.3%

This was found in a systematic review.

Question 14

When should an LP be performed?

Answer 14

12 hours (for the exam)

Earlier can result in false positive is the rationale but there is no evidence

Question 15

What is a major vascular complication occurring between 2-14 days of SAH and what drug can be given?

Answer 15

Vasospasm (30% die and 30% permanent Neuro deficit)

Nimodipine - start w/in 96hrs

Question 16

What % of SAH patients have a seizure?

Answer 16

20%

Question 17

What is the recommended dosage of Nimodipine for SAH?

Answer 17

60 mg orally Q4H for 21 days

Question 18

When should Nimodipine be administered?

Answer 18

As soon as SAH is confirmed

Question 19

When does vasospasm typically peak after SAH?

Answer 19

3-10 days after SAH

Question 20

What additional medication should be given alongside Nimodipine to reduce vasospasm?

Answer 20

Magnesium

Question 21

What is the target systolic blood pressure (SBP) for managing SAH?

Answer 21

SBP < 140

Question 22

What is the target mean arterial pressure (MAP) range for SAH management?

Answer 22

MAP < 110 and MAP > 80

Question 23

What analgesic can be used in management alongside Nimodipine?

Answer 23

Fentanyl

Question 24

What is the dosing regimen for labetolol in SAH management?

Answer 24

20 mg Q10min, max 80 mg

Question 25

What are the reversal agents for anticoagulation in warfarin patients?

Answer 25

Vitamin K 5-10mg prothrombinex 50 units/kg FFP 300mls

Question 26

What should be considered for patients on aspirin and clopidogrel?

Answer 26

Platelets

Question 27

What is the role of TXA in SAH management according to the ULTRA trial?

Answer 27

No role

Question 28

Which medication is recommended for seizure prophylaxis in SAH?

Answer 28

Levetiracetam (Keppra) 60mg/kg MAX dose 4500mg

Question 29

What intervention is preferred according to the BRAT trial?

Answer 29

Coiling

Question 30

What are the major complications to seek and treat in SAH?

Answer 30

* Rebleeding * Hydrocephalus * Vasospasm * Cardiogenic complications * Neurogenic pulmonary edema * Fever * Hyponatraemia / hypernatraemia Neurogenic pulm oedema is caused by sympathetic hyperactivity (catecholamine surge) -> can be early minutes to hours or delayed

Question 31

When does most rebleeding occur after SAH?

Answer 31

Most rebleeding occurs within the first 6 hours and carries a mortality of 40%

Question 32

What are the risk factors for SAH?

Answer 32

* Hypertension * Smoking * ETOH * Female * Old age * Personal history (PHx), Family history (FHx) * Polycystic disease

Question 33

What should not be diagnosed in a patient's first episode of severe headache?

Answer 33

Tension headache or migraine ## Footnote Making these diagnoses can lead to mismanagement of the patient's condition.

Question 34

What may patients with subarachnoid hemorrhage (SAH) experience besides headache?

Answer 34

Secondary head injury, hypertension, ECG changes, mild pyrexia ## Footnote These symptoms can complicate the clinical picture.

Question 35

Is the pain associated with SAH always occipital?

Answer 35

No ## Footnote Pain can present in various locations and is not limited to the occipital region.

Question 36

What type of pain may indicate a middle cerebral artery aneurysm?

Answer 36

Eye or temple pain ## Footnote This symptom can be a crucial indicator of a more serious condition.

Question 37

Is photophobia a sensitive or specific symptom for SAH?

Answer 37

Neither sensitive nor specific ## Footnote Its presence alone cannot confirm or rule out SAH.

Question 38

What cranial nerve palsies may be associated with SAH?

Answer 38

3rd, 5th, or 6th cranial nerve palsies ## Footnote These may indicate complications related to SAH.

Question 39

What ECG changes may mimic ischemia in SAH?

Answer 39

ST & T wave changes ## Footnote This can lead to misinterpretation of the ECG findings.

Question 40

What are some specific ECG findings in SAH?

Answer 40

Widened QRS, Prolonged QI, Peaked or deeply inverted T waves, ST elevation rare ## Footnote These findings can provide diagnostic clues in the context of SAH.

Question 41

How do you treat neurogenic pulmonary oedema?

Answer 41

Supportive Protective lung strategy Mild diuresis (need to maintain cerebral blood flow) ICP control main end point to reduce sympathetic drive

Question 42

What percentage of SAH cases occur during exertion?

Answer 42

25-40%