endovascular treatment of subarachnoid...
TRANSCRIPT
Subarachnoid
Hemorrhage
• Blood in subarachnoid space
• Causes:
– Aneurysm Rupture (75-80%)
– Arterial- Venous malformation
– Trauma
– Vasculitis
– Tumor
– Spinal AVM
Aneurysms
• 50% mortality
• Rupture rate based on size and location –
ISUIA data
• Rerupture rate highest in first 48 hours
• Hydrocephalus, arrhythmias
• Vasospasm
SAH PROTOCOL
• 1. Nimotop : x21d. (only FDA approved drug)
• 2. Statinx14d
• 3. Mag oxideX14d
• 4. Echo
• 5. Troponin x3
• 6. TCD x10d
Medical Treatment
• Admitted to ICU
• Nimotop, zocor, Magnesium
• MAP 70-90 before treatment
• MAP >80 after treatment
• IVFs
• TCDs
• Watch Na – cerebral salt wasting
VASOSPASM
• 1. One of leading
causes of morbidity and
mortality post SAH.
• 2. Peak Day 3-10.
• 50-70% have it, 30-
50% have symptoms.
• Diagnosis: CLINICAL
most important, TCD,
cerebral angio
• CLINICAL:
• Lethargy
• Change in speech,
weakness, hemiparesis
• Vision change
• Any NEURO change
Vasospasm
Cascade
• 1. Increased levels of
Ca+ in smooth muscle:
increased muscle
contraction and vessel
contraction of vessel
wall
• 2. Increased vasoactive
substances
• 3. Structural arterial
wall injury
Treatment Vasospasm
• 1. Induced HTN: Map >110 NEO/LEVO
• 2. Fluid Volume normal
• 3. Intra-arterial Verapamil
• 4. Nimotop. Ca+blocker. Relaxes smooth muscle cells in brain.
• 5. Magnesium: Ca+ antagonist, decrease free radicals, inflammation.
• 6. Statin: neuro protective. Stabilize endothelium.
• 7. HHH: Hypertension/hemodilution/hydration
TCD
TRANSCRANIAL
DOPPLER
• Measure velocity of
blood flow in cerebral
arteries.
• Daily for 10-14days
• Monitor for vasospasm.
(3-10d)
• Not 100%, need clinical
exam.
• PEAK: <150
ALBUMIN
• 25% Albumin: volume expander
• ALISAH study 2006-2010.
• Has neuroprotective properties, increase
cerebal blood flow/collateral flow in animal
studies
• Keep hydrated, hold on to NA.
HYPONATREMIA
FLORINEF NA TABS
• Glucocorticoid
• Help maintain salt and
H20 balance.
• Most common electrolyte
imbalance in SAH. (30-
50%).
• 1-2gm TID
• Taper upon dc/transfer
AVM
• Considered to be congenital lesions
• Bed of dilated arteries and veins directly
connected with no capillary bed
• Prevalence:0.14%
• Usually presents with ICH or seizures
• Bleeding risk 2-4% per year
• Morbidity 30-50%, mortality 10%