subarachnoid hemorrhage
DESCRIPTION
Subarachnoid Hemorrhage. subarachnoid space. ventricles. Incidence of Aneurysmal SAH. Studies suggest that the incidence in the USA and Europe is 10 to 11 cases per 100,000 population per year - PowerPoint PPT PresentationTRANSCRIPT
Subarachnoid Subarachnoid HemorrhageHemorrhage
subarachnoid space
ventricles
Incidence of Incidence of Aneurysmal SAHAneurysmal SAHStudies suggest that the incidence in Studies suggest that the incidence in the USA and Europe is 10 to 11 cases the USA and Europe is 10 to 11 cases per 100,000 population per yearper 100,000 population per year
Overall, less than 2% of the entire Overall, less than 2% of the entire population will have an aneurysm; an population will have an aneurysm; an intracranial aneurysm will rupture in intracranial aneurysm will rupture in less than 1% of the population and less than 1% of the population and will be the cause of death in 0.5%will be the cause of death in 0.5%
Age and the Incidence of Age and the Incidence of Aneurysmal SAHAneurysmal SAH
Aneurysmal rupture is extremely Aneurysmal rupture is extremely rare in the first decade of liferare in the first decade of life
Incidence gradually increases each Incidence gradually increases each decade and peaks in the sixth decade and peaks in the sixth decadedecade
Gender and the Gender and the Incidence of Aneurysmal Incidence of Aneurysmal SAHSAHThere is a clear female preponderance There is a clear female preponderance overall; the ratio of females to males overall; the ratio of females to males is 1.6: 1is 1.6: 1
Before age 40 males and females were Before age 40 males and females were equally affected; after age 40 there equally affected; after age 40 there is an increasingly strong is an increasingly strong predominance of femalespredominance of females
Natural HistoryNatural HistoryPrognosis for Surgically Untreated SaccularPrognosis for Surgically Untreated SaccularIntracranial AneurysmsIntracranial Aneurysms
OVERVIEWOVERVIEW
Highest mortality occurs immediately after Highest mortality occurs immediately after the hemorrhage and then decreases rapidlythe hemorrhage and then decreases rapidly
Rebleeding is estimated to occur in 50% of Rebleeding is estimated to occur in 50% of ruptured aneurysms within 6 months of the ruptured aneurysms within 6 months of the first hemorrhage, and afterwards at 3% per first hemorrhage, and afterwards at 3% per yearyear
50-60%50-60% of patients die after rebleeding and of patients die after rebleeding and 25% are left disabled25% are left disabled
Mortality at 1 day was 32%Mortality at 1 day was 32%
Mortality at 1 week was 43%Mortality at 1 week was 43%
Mortality at 1 month was 56%Mortality at 1 month was 56%
Mortality at 6 months was 60%Mortality at 6 months was 60%
Clinical presentationsClinical presentations
A lot of symptoms with minimal signsA lot of symptoms with minimal signs::
11--severe thunder clump headachesevere thunder clump headache
22--repeated projectile vomitingrepeated projectile vomiting
33--photophobiaphotophobia
44--meningeal signsmeningeal signs
55--papilodema +/- subhyloid Hmpapilodema +/- subhyloid Hm
Clinical Grading Scales for Clinical Grading Scales for SAHSAH
Grade DescriptionGrade Description
Hunt and Hess ScaleHunt and Hess Scale
11 Asymptomatic or minimal headache and slight nuchal Asymptomatic or minimal headache and slight nuchal rigidityrigidity
22 Moderate to severe headache, nuchal rigidity, no Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsyneurological deficit other than cranial nerve palsy
33 Drowsiness, confusion, or mild focal deficitDrowsiness, confusion, or mild focal deficit
44 Stupor, moderate to severe hemiparesis, possible Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbancesearly decerebrate rigidity and vegetative disturbances
55 Deep coma, decerebrate rigidity, moribund Deep coma, decerebrate rigidity, moribund appearanceappearance
Clinical Grading Scales for Clinical Grading Scales for SAH SAH .../cont’d.../cont’d
Grade DescriptionGrade Description
World Federation of Neurological Surgeons World Federation of Neurological Surgeons ScaleScale
11 Glasgow coma scale 15, no motor deficitGlasgow coma scale 15, no motor deficit
22 GCS 13 to 14, no motor deficitGCS 13 to 14, no motor deficit
33 GCS 13 to 14, with motor deficitGCS 13 to 14, with motor deficit
44 GCS 7 to 12, with or without motor deficitGCS 7 to 12, with or without motor deficit
55 GCS 3 to 6, with or without motor deficitGCS 3 to 6, with or without motor deficit
Diagnosis of Subarachnoid Diagnosis of Subarachnoid
HemorrhageHemorrhage ((
Headaches accounts for 1-2% of Headaches accounts for 1-2% of visits to ER; 1% of theses have visits to ER; 1% of theses have SAHSAH
About 80% of patients with About 80% of patients with nontraumatic SAH have a ruptured nontraumatic SAH have a ruptured saccular aneurysm; of the other saccular aneurysm; of the other 20%, about 1/2 have 20%, about 1/2 have nonaneurysmal perimesencephalic nonaneurysmal perimesencephalic hemorrhageshemorrhages
••The first diagnostic test should be The first diagnostic test should be non-contrast CT scanningnon-contrast CT scanning
••Timing of the CT scan in relation to Timing of the CT scan in relation to SAH ictus is important; positive SAH ictus is important; positive results decrease with time; 98-results decrease with time; 98-100% are positive up to 12 hours 100% are positive up to 12 hours after the ictus and 93% are positive after the ictus and 93% are positive in the first 24 hoursin the first 24 hours
Diagnosis of Subarachnoid Hemorrhage .../cont’d
LP should be performed in patients whose LP should be performed in patients whose clinical presentation suggests SAH and clinical presentation suggests SAH and whose CT is negativewhose CT is negative
‘‘Traumatic Tap’ occurs in up to 20% of LPs; Traumatic Tap’ occurs in up to 20% of LPs; Released hemoglobin is metabolized to the Released hemoglobin is metabolized to the pigmented molecular oxyhemoglobin pigmented molecular oxyhemoglobin (reddish pink) and bilirubin (yellow), resulting (reddish pink) and bilirubin (yellow), resulting in xanthochromia. Oxyhemoglobin can be in xanthochromia. Oxyhemoglobin can be detected within hours, but the formation of detected within hours, but the formation of
bilirubin requires up to 12 hours to occurbilirubin requires up to 12 hours to occur . .
Diagnosis of Subarachnoid Hemorrhage .../cont’d
cathetercatheterarteriographyarteriography
anterioranteriorcirculationcirculation
posteriorposteriorcirculationcirculation
CT scan of a subarachnoid hemorrhage (SAH)
Treatment:Treatment:the aim of the treatment isthe aim of the treatment isto prevent a new rupture of the aneurysmto prevent a new rupture of the aneurysm
options:options:Medical non aneurysmal or surgery is contraindication Medical non aneurysmal or surgery is contraindication
surgical surgical clip or endovascular coilsclip or endovascular coils
Medical treatmentMedical treatment
11--Complete rest, sedation, keep the Complete rest, sedation, keep the patient in dark roompatient in dark room
22--AnalgesicAnalgesic
33--IV fluid (2/3 of the requirement)IV fluid (2/3 of the requirement)
44--Nimodipine 60mg every 4hoursNimodipine 60mg every 4hours
55--LaxativeLaxative
66--Control the BPControl the BP
clipclipopen surgeryopen surgery
where is the aneurysm?where is the aneurysm?
SAHSAH
where is the aneurysm?where is the aneurysm?
surgical clipsurgical clip
beforebefore afterafter
coilscoilsendovascular treatmentendovascular treatment
SAHSAH
rupture of an aneurysm rupture of an aneurysm at the tip of the basilar at the tip of the basilar arteryartery
beforebefore afterafter