SUBARACHNOID HEMORRHAGE

Question 1

MANAGEMENT

Answer 1

1. IMAGING
   CT Head:
   Sensitivity declines with time

100% Sensitivity and 100% Negative Predictive Value if done within 6 hours

2. LUMBAR PUNCTURE:
   LP performed within 12 hours of onset may have false negative results because blood has not diffused down

LP Contraindications
Infection at the site of the LP
Coagulation abnormalities
Risk of brain herniation

CSF opening pressure (if done in left lateral decubitus)

Tube 1 - cell count, gram stain, xanthocromia

Tube 2 - protein, glucose

Tube 3 - culture & sensitivity, viral studies

Tube 4 - cell count

Low grade evidence for CTA as an alternative to LP where clinical concern for a aneurysmal SAH persists despite a negative non-contrast CT Head

INITIAL MANAGEMENT

2. EARLY NEUROSURGICAL CONSULTATION
3. PAIN CONTROL

4, BLOOD PRESSURE MANAGEMENT: Lower SBP < 160

Labetolol
Dosing: 20 mg IV with additional doses 20, 40, 80 to total 300 q 10 min
OR
1-2 mg / min

C/I:
Pheochromocytoma, CHF, Asthma, Heart Block

Hydralazine:
Dosing: 5 mg IV, repeat 5-10 mg q 20 min
Goal DBP<110

5. REVERAL OF COAGULOPATHY
   Warfarin with elevated INR: Octaplex (PCC) 80mL (2000 U) + 10 mg Vit K IV, hold Warfarin, repeat INR.
   Goal INR < 1.4
   Plt goal > 100 k
   DDVAP if uremic

Rivaroxaban / Apixaban / Edoxaban: Octaplex (PCC) 80mL (2000 U) +/- 10 mg Vit K IV if elevated INR

Heparin: Protamine Sulfate (time dependent dosing)

Dabigatran: idarucizumab 5 g IV
fXa: andexamet, TXA
Thrombocytopenia: platelet transfusion

6. PREVENTION OF VASOSPASM
   Nimodipine 60 mg q 4 h 21 days
7. SEIZURE PPX
   Keppra: 40-60 mg / kg IV loading dose at a rate of 5-15 min), max 2000-4000 mg IV load
8. ICP MANAGEMENT
   Elevate head of bed to 30 degrees
   Mannitol 0.5-1 g/kg intravenous
   20 g / 100 ml
   3% hypertonic saline 100 mL intravenous
   Intubate, sedate, +/- paralyze
   Drain excessive CSF with intraventriculoperitoneal shunt

Question 2

DOCUMENTATION

Answer 2

1. CLINICAL FEATURES
   Thunderclap Headache
   Onset w/ exertion
   Loss of Consciousness
   Nuchal pain or rigidity
2. FEATURES THAT INCREASE THE LIKELIHOOD OF SAH
   Reaches max intensity within a hour
   Arrival by ambulance
   Age >= 40
   Neck Pain or Stiffness
   Onset with exertion
   Vomiting
   Witnessed loss of consciousness
   Elevated blood pressure
3. TIME OF CT READ

Factors that contribute to ruling out SAH with 100% Sensitivity:
Negative CT
Normal Opening Pressure
Negative LP

4. LUMBAR PUNCTURE
   Positive Finding:
   Xanthochromia
   Elevated Opening Pressure

Normal Opening Pressure: 50 - 200 mmH20

5. TIME OF NEUROSURGICAL CONSULTATION