Neurosurgery Case 3: Subarachnoid Hemorrhage

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Neurosurgery Case 3: Subarachnoid Hemorrhage. 3Med – C UST-FMS. Sudden right-sided headache Bout of vomiting, progressive deterioration in LOC. 57 y/o housewife. Few minutes PTA. Admission. Physical Exam Restless, disoriented and non-communicative BP: 198/102 Afebrile - PowerPoint PPT Presentation

Text of Neurosurgery Case 3: Subarachnoid Hemorrhage

Neurosurgery Case 3: Subarachnoid Hemorrhage

Neurosurgery Case 3:Subarachnoid Hemorrhage3Med CUST-FMS

57 y/o housewifeAdmissionFew minutes PTASudden right-sided headacheBout of vomiting, progressive deterioration in LOCPhysical ExamRestless, disoriented and non-communicativeBP: 198/102Afebrile(+) nuchal rigidityPtosis of right eyelidFundoscopy: suspicious hemorrhagePast Medical HistoryHad previous milder headache 3 days priorRecently under initial treatment and observation for hypertension

Personal & Social HistoryFormer smokerTook OCPs during premenopausal yrs

Ancillary ProceduresLP and/or cranial CT: confirmed earlier impression of subarachnoid hemorrhageAngiogram: presence of aneurysm and a complicating vasospasmSalient Features57 y/o femaleSudden severe headacheVomitingProgressive deterioration in LOCHTN (198/102 mmHg)Afebrile(+) nuchal rigidityptosis of right eyelidFundoscopy: suspicious hemorrhageSmokerOral contraceptive useRecent episodes of hypertension

CT scan: SAHAngiogram: aneurysm with complicating vasospasm

SUBARACHNOID HEMORRHAGECauses of Subarachnoid Hemorrhage:Bleeding from a cerebral aneurysm (85%)Bleeding from an arteriovenous malformation (AVM) Bleeding disorder Head injury (Traumatic SAH) Unknown cause (idiopathic) Use of blood thinners (anticoagulant therapy)In 85% of cases of spontaneous SAH, the cause is rupture of a cerebral aneurysm-a weakness in the wall of one of the arteries in the brain that becomes enlargedmost cases of SAH are due to bleeding from small aneurysms, larger aneurysms (which are less common) are more likely to rupture.AVM: Abnormal, tangled collections of dilated blood vessels that result from congenitally malformed vascular structures in which arterial afferents flow directly into venous efferents without the usual resistance of an intervening capillary bed. Traumatic SAH (tSAH) usually occurs near the site of a skull fracture or intracerebral contusion.It has been linked with a poorer prognosis.Injury-related subarachnoid hemorrhage is often seen in the elderly who have fallen and hit their head.Among the young, the most common injury leading to subarachnoid hemorrhage is motor vehicle crashes.Subarachnoid hemorrhage due to rupture of a cerebral aneurysm:occurs in approximately 10-15 out of 10,000 most common in persons age 20 to 60. It is slightly more common in women than men.Cocaine abuse and sickle cell anemia (usually in children) and, pituitary apoplexy (infarction or hemorrhage of the pituitary gland in the presence of a pituitary adenoma) can also result in SAH.8Risks include:Fibromuscular dysplasia (FMD) and other connective tissue disorders associated with aneurysm or weakened blood vessels High blood pressure History of polycystic kidney disease polycystic kidney disease Smoking strong family history of aneurysms

Fibromuscular dysplasia of arteries: A rare disease where the blood vessel walls thicken and harden which reduces blood flow through the arteries and into various organs.

Subarachnoid hemorrhage may reflect a secondary dissection of blood from an intraparenchymal hematoma (eg, bleeding from hypertension or neoplasm).

Congenital causes also may be responsible for subarachnoid hemorrhage. Occasional familiar occurrence Frequency of multiple aneurysms Association of aneurysms with specific systemic diseases, including Ehlers-Danlos syndrome, Marfan syndrome, coarctation of the aorta, and polycystic kidney disease

Environmental factors associated with acquired vessel wall defects include age, hypertension, smoking, and arthrosclerosis9SAH Clinical presentationHypertensive on admissionHistory of poorly controlled hypertensionLethargy or obtundationDepressed mental status results from brain shift and herniation secondary to mass effect from the hematoma in deep structuresGradual decline in neurologic function as hematoma expandsSchwartzs Principles of Surgery, 9th EdRupture of cerebral aneurysmResults in SAHSudden, severe thunderclap headacheHunt-Hess grading system categorizes patients clinicallySchwartzs Principles of Surgery, 9th Ed11** Hunt-Hess will be discussed in question 4Diagnostic TestsCT scan of the Headmodality of choice generally required to confirm or exclude bleeding.

The diagnosis can be made with the help of medical hisrory and physical exam but it cant be made merely by doing that; thereforemedical imagingis generally required to confirm or exclude bleeding. The modality of choice iscomputed tomography(CT scan) of the brain. This has a highsensitivityand will correctly identify over 95% of casesespecially on the first day after the onset of bleeding.Magnetic resonance imaging(MRI) may be more sensitive than CT after several days.[1]

CT scan of the brain showing subarachnoid hemorrhage as a white area in the center and stretching into thesulcito either side (marked by the arrow)

:: Lumbar puncture(spinal tap)a procedure to determine if there is blood in the cerebrospinal fluid:: Angiograma type of x-ray that takes images of the brain's blood vessels after dye is injected in the bloodstreamCT angiograma type of x-ray that looks at the blood vessels in the head and neck:: MRI scana test that uses magnetic waves to make pictures of structures inside the brain and neck

12Diagnostic TestLumbar Puncture mandatory in people with suspected SAH if imaging is negative if an elevated number of RBCs is present equally in all 3 bottles this indicates SAH

In the picture: Alumbar puncturein progress. A large area on the back has been washed with aniodinebased disinfectant leaving brown colouration

Lumbar puncture, in whichcerebrospinal fluid(CSF) is removed with a needle from thelumbarsac, will show evidence of hemorrhage in 3% of people in whom CT was found normal.

At least three tubes of CSF are collected.[6]If an elevated number ofred blood cellsis present equally in all bottles, this indicates a subarachnoid hemorrhage. If the number of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the procedure (known as a "traumatic tap").[

13 CSF sample is also examined forxanthochromia more sensitive is spectrophotometry for detection of bilirubinDiagnostic Test

The CSF sample is also examined forxanthochromiathe yellow appearance ofcentrifugatedfluid. More sensitive isspectrophotometry(measuring the absorption of particular wavelengths of light) for detection ofbilirubin, a breakdown product ofhemoglobinfrom red blood cells.[1][13]Xanthochromia and spectrophotometry remain reliable ways to detect SAH several days after the onset of headache.[13]An interval of at least 12hours between the onset of the headache and lumbar puncture is required, as it takes several hours for the hemoglobin from the red blood cells to be metabolized into bilirubin.14Diagnostic TestAngiographyUsed after the SAH is confirmed, it origin needs to be determined

After a subarachnoid hemorrhage is confirmed, its origin needs to be determined. If the bleeding is likely to have originated from an aneurysm (as determined by the CT scan appearance), the choice is betweencerebral angiography(injecting radiocontrast through acatheterto the brain arteries) andCT angiography(visualizingblood vesselswithradiocontraston a CT scan) to identify aneurysms. Catheter angiography also offers the possibility of coiling an aneurysm (see below).[1][3

From : E-MEDICINE JOURNALS:Cerebral angiography is considered the standard imaging technique for the detection of intracranial aneurysms, AVMS, and fistulae, as shown in the images below. Aneurysms are detected as focal areas of outpouching or dilatation of the arterial wall. These frequently occur at arterial branching points in characteristic locations within or near the circle of Willis. Cerebral angiography should include anteroposterior (AP), lateral, and one or more oblique views of both carotid and vertebral artery contrast injection studies. A submentovertical view is sometimes useful in demonstrating the neck of a middle cerebral artery bifurcation aneurysm or anterior communicating artery aneurysm.

IN THE PICTURE: 1. An angiogram showing a bilobed aneurysm of a posteroinferior cerebellar artery immediately before rupturing.

2. A late angiogram demonstrating contrast medium filling the posterior fossa subarachnoid spaces, including the ambient, prepontine, and perimedullary cisterns.

15Diagnostic TestECG QT prolongation, Q waves, cardiac dysrhythmias and ST elevation - mimics a heart attack

changes are relatively common in subarachnoid hemorrhage, occurring in 4070% of cases. They may includeQT prolongation,Q waves,cardiac dysrhythmiasandST elevationthat mimics aheart attack

In the picture: ECG changes resembling those of an STEMI in a woman who had an acute CNS injury from a subarachnoid hemorrhage.16HUNT & HESS SCALE FOR GRADING SUBARACHNOID HEMORRHAGEGradeMotor Deficit0Intact Aneurysm1Asymptomatic.Mild headache and slight nuchal rigidity.1aNo acute meningeal/brain reaction but with fixed neurological deficit.2Cranial nerve palsy.Moderate to severe headache.Nuchal rigidity.3Mild focal deficit.Lethargy or confusion.4Stupor.Moderate to severe hemiparesis.Early decerebrate rigidity.5Deep coma.Decerebrate rigidity.Moribund appearance.

MANAGEMENT: SUBARACHNOID HEMORRHAGEMORALEDAFRANCIS BANEURYSM RUPTURE = SAHThe major cerebral vessels, and therefore aneurysms (focal dilatation of the vessel wall), lie in the subarachnoid space. Rupture results in SAH. The aneurysmal tear may be small and seal quickly, or it may not. SAH may consist of a thin layer of blood in the CSF spaces, or thick layers of blood around the brain and extending into brain parenchyma, resulting in a clot with mass effect. Meningeal linings of the brain are sensitive, SAH usually resul