Subarachnoid hemorrhage and Vasospasm

  • View
    5.737

  • Download
    7

Embed Size (px)

Text of Subarachnoid hemorrhage and Vasospasm

  • 1.SAHandVasospasm: EmergingTherapies Dr. Stuart Wright MD PhDPGY 5 CCM Fellow

2. Objec9ves Subarachnoidhemorrhage Vasospasm Pathophysiology Currenttherapies Emergingtherapies 3. CaseScenario A45yearoldwoman,whofrequentlypresentswithmigrainereportsher"worstmigraineever"andonspecicques9oningreportsasuddenonsetoccipitalheadachenowgeneralisedwithassociatedvomi9ng.Sherequestsanalgesiaandanan9eme9csothatshecan"sleepitoathome"andhasbroughthersontodriveherhome. 4. ClinicalFeatures SuddenonsetHAthatlasts1-2weeks(74%) Vomi9ng(77%) DecreasedLOC(53%) Nuchalrigidity(35%) Focaldecit(15%) Seizures(7%) 5. Missedbecausesudden,severeheadacheisnotpresentin25%ofpa9ents 1in10withsuddenheadache,SAHisthecause Missedin20-50%ofpa9entsatrstpresenta9on 6. Diagnosis CTscanANDlumbarpunctureifscanisnega9ve IfSAHisfound,itisusuallyfollowedwithcathetercerebralangioorMR/CTangiotodocumenttheanatomicfeatures CTscandetects93-98%ofSAH 7. NewestGuidelines 8. SubarachnoidHemorrhage Commonanddevasta9ngcondi9onaec9ngyoungerpa9ents Accountsfor3-8%ofallstrokes Responsiblefor25%ofyearslostduetostroke 7-20per100,000peopleannually 9. SAH Outcomesarepoor Mortality,50%fromSAH Morbidity,15%severelydisabled Only20-35%ofpa9entswillhavemoderatetogoodrecovery 10. SAH Incidencestableoverlast4decades Incidenceincreaseswithage(mean50years) Femalesmorethanmales(1.6x) BlackNorthAmericanshigherriskthanwhite 11. Riskfactors HTN Heavyalcoholuse Smoking Sympathomime9cdrugs(cocaine) Previousrupturedaneurysm Congenital PCKD EhlersDanlostypeIV 12. Preopera9vecare BloodpressureshouldbemonitoredandcontrolledbalanceofCPPvsHTNinducedrebleed SBP130)resultedininc.CBFandbrainoxygena9on Hypervolemiahadminimaltonoeect HHHcomboreversedHTNeectsonbrainoxygena9on 31. TripleHTherapy StandardtripleHtherapyshouldbemodied HTNwithcarefulvolumeexpansionshouldbethenewstandard 32. Sta9ns! 33. Sta9nsandSAH Sta9nsnotonlyfunc9ontolowercholesterolbutarealsopotentNOinducersanddown-regulatorsofinamma9on Observa9onalstudiesofsta9nuseinpa9entswereencouraging 34. Sta9nsandSAH 12-foldincreaseinoddsofsurvivingSAHifpreviouslyonsta9ns 35. Statin treatment reduces need for traditional rescue therapy, and improved outcome in physical and psychosocial function at 6 months 36. vasospasm morbidity and mortality reduced by 83 and 75%, respectively incidence and severity were reduced by 32% duration of vasospasm was shortened by 0.8 days 37. BUT.. Variousgroupsaddedthetherapyintotheirstandardcare Nowstar9ngtogetreportsoftheiroutcomeanalyses 38. All patients were started on a statin on admission and no clinical difference was noted 39. Sta9ns SowhatdoesthismeanfortheuseofSta9ns: Theydontappeartobeagoodrescuetool Butifyouwereonitfor>1monthpriortoeventthereisan11-foldharmreduc9on 40. Magnesium Calciumantagonist Goodsafetyprole Comparabletonimodipinealone Nostudiesaddingtonimodipine 41. Magnesium 34%Reduc9onindelayedcerebralischemia 23%Reduc9oninpooroutcomeat3months 42. Clazosentan ETAantagonistinPhaseIItrial CONSCIOUS-1study Decreasedincidenceofvasospasm,DIND,andinfarctsonCTindose-dependentmanner BUT,noreduc9oninmortality(underpowered) CONSCIOUS-2,currentlyenrolling 43. NOdonors Genetherapywaytooexperimental Intraventricularadministra9onofsodiumnitroprussidetriedin10pa9entswithmedicallyrefractoryvasospasm3ptshadexcellentoutcome Moretocome 44. EPO Maybeneuroprotec9ve Maypreventvasospasmbyincreasingac9va9onofeNOSNOdonor S9llpreliminary 45. Conclusion SAHisadevasta9ngproblemaec9ngyoungerpopula9on Vasospasmisaknownpoten9allymodiableproblemwithsignicantmorbidityandmortality 46. Conclusion Preven9onofvasospasm: Oralnimodipineisofprovenbenet Star9ngasta9njurys9llout Ifapa9entisonasta9n,con9nueitASAP RescuetherapyforvasospasmisbeuercoinedasHypertensivetherapywithjudiciousvolumemaintenance 47. Conclusion Magnesiumtherapymaybeofbenetifaddedtonimodipineorifnimodipineiscontraindicated Therearespecictargetss9llunderinves9ga9onandtherapiesinthepipelinebutnotreadyforprime-9me