Subarachnoid Hemorrhage. subarachnoid space ventricles

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Subarachnoid Hemorrhage Slide 2 subarachnoid space ventricles Slide 3 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 Overall, less than 2% of the entire population will have an aneurysm; an intracranial aneurysm will rupture in less than 1% of the population and will be the cause of death in 0.5% Slide 4 Age and the Incidence of Aneurysmal SAH Aneurysmal rupture is extremely rare in the first decade of life Incidence gradually increases each decade and peaks in the sixth decade Slide 5 Gender and the Incidence of Aneurysmal SAH There is a clear female preponderance overall; the ratio of females to males is 1.6: 1 Before age 40 males and females were equally affected; after age 40 there is an increasingly strong predominance of females Slide 6 Natural History Prognosis for Surgically Untreated Saccular Intracranial Aneurysms OVERVIEW Highest mortality occurs immediately after the hemorrhage and then decreases rapidly Rebleeding is estimated to occur in 50% of ruptured aneurysms within 6 months of the first hemorrhage, and afterwards at 3% per year 50-60% of patients die after rebleeding and 25% are left disabled Slide 7 Mortality at 1 day was 32% Mortality at 1 week was 43% Mortality at 1 month was 56% Mortality at 6 months was 60% Slide 8 Clinical presentations A lot of symptoms with minimal signs: 1-severe thunder clump headache 2-repeated projectile vomiting 3-photophobia 4-meningeal signs 5-papilodema +/- subhyloid Hm Slide 9 Clinical Grading Scales for SAH Grade Description Hunt and Hess Scale 1 Asymptomatic or minimal headache and slight nuchal rigidity 2 Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy 3 Drowsiness, confusion, or mild focal deficit 4 Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbances 5 Deep coma, decerebrate rigidity, moribund appearance Slide 10 Clinical Grading Scales for SAH.../cont d Grade Description World Federation of Neurological Surgeons Scale 1 Glasgow coma scale 15, no motor deficit 2 GCS 13 to 14, no motor deficit 3 GCS 13 to 14, with motor deficit 4 GCS 7 to 12, with or without motor deficit 5 GCS 3 to 6, with or without motor deficit Slide 11 Diagnosis of Subarachnoid Hemorrhage ( Headaches accounts for 1-2% of visits to ER; 1% of theses have SAH About 80% of patients with nontraumatic SAH have a ruptured saccular aneurysm; of the other 20%, about 1/2 have nonaneurysmal perimesencephalic hemorrhages Slide 12 The first diagnostic test should be non- contrast CT scanning The first diagnostic test should be non- contrast CT scanning Timing of the CT scan in relation to SAH ictus is important; positive results decrease with time; 98-100% are positive up to 12 hours after the ictus and 93% are positive in the first 24 hours Timing of the CT scan in relation to SAH ictus is important; positive results decrease with time; 98-100% are positive up to 12 hours after the ictus and 93% are positive in the first 24 hours Diagnosis of Subarachnoid Hemorrhage.../contd Slide 13 LP should be performed in patients whose clinical presentation suggests SAH and whose CT is negative Traumatic Tap occurs in up to 20% of LPs; Released hemoglobin is metabolized to the pigmented molecular oxyhemoglobin (reddish pink) and bilirubin (yellow), resulting in xanthochromia. Oxyhemoglobin can be detected within hours, but the formation of bilirubin requires up to 12 hours to occur. Diagnosis of Subarachnoid Hemorrhage.../contd Slide 14 catheterarteriography Slide 15 Slide 16 anteriorcirculation Slide 17 posteriorcirculation Slide 18 CT scan of a subarachnoid hemorrhage (SAH) Slide 19 Treatment: the aim of the treatment is to prevent a new rupture of the aneurysm options: Medical non aneurysmal or surgery is contraindication surgical clip or endovascular coils Slide 20 Medical treatment 1-Complete rest, sedation, keep the patient in dark room 2-Analgesic 3-IV fluid (2/3 of the requirement) 4-Nimodipine 60mg every 4hours 5-Laxative 6-Control the BP Slide 21 clip open surgery Slide 22 where is the aneurysm? SAH Slide 23 Slide 24 surgical clip Slide 25 beforeafter Slide 26 coils endovascular treatment Slide 27 Slide 28 Slide 29 Slide 30 SAH rupture of an aneurysm at the tip of the basilar artery Slide 31 Slide 32 beforeafter