Tom Bleck - Subarachnoid Hemorrhage: What Matters?

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SNACC 2015:Subarachnoid Hemorrhage:What Matters?Thomas P. Bleck MD MCCM FNCSProfessor of Neurological Sciences, Neurological Surgery, Internal Medicine, and Anesthesiology, Rush Medical College; andDirector, Clinical Neurophysiology, Rush University Medical Center


DisclosuresI am a current member of the ABIM Critical Care Subspecialty Exam Committee.To protect the integrity of Board Certification, ABIM enforces strict confidentiality and ownership of exam content.As a member of an ABIM exam committee, I agree to keep exam information confidential.As is true for any ABIM candidate who has taken an exam for Certification, I have signed the Pledge of Honesty in which I have agreed not to share ABIM exam questions with others.No exam questions will be disclosed in my presentation.

Standard disclosures Research support from NINDS, AHA, ZollConsultant for USAMRICD (nerve agent protection)DSMB chair for Sage phase 3 trial of allopregnenolone in RSEDSMB member for a trial of ketogenic diet in RSEDSMB chair for a trial of intraventricular nimodipine in SAH

Many of the treatments discussed are not approved by the FDA

SAH: What matters?Rapidly identify patients with aneurysmal SAH and secure their aneurysm(s) quicklyLower MAP before securing the aneurysm but not afterwardsDetect and manage early complicationsStress cardiomyopathyNeurogenic pulmonary edemaCerebral salt wasting

SAH: what matters?Detect vasospasm early ClinicalElectrophysiologic SonographicRadiologicManage clinical vasospasm aggressivelyAugment pressure and flowAngioplasty and IA vasodilators

Critical care issues: rebleedingUnsecured aneurysms:9% 17% rebleed on day 0, then1.5%/day for next 13 days [ up to 36% for 2 weeks]Antifibrinolytic therapy (e.g., aminocaproic acid)may be useful between presentation and early surgeryBlood pressure managementlabetalol, hydralazine, nicardipineAnalgesiaMinimal or no sedation to allow examination

Radiographic diagnosis of vasospasmOnly half of patients with angiographic vasospasm have clinical findings related to the arteries involvedDSA is currently the standard methodGood definition of large and medium vesselsAllows angioplasty and intra-arterial therapyCTA for the diagnosis of vasospasm is increasing in useDistal spasm may be more difficult to detect by CTAWhat about microvasospasm?

Critical care issues: vasospasm and delayed ischemic damageProphylaxisclot removalvolume repletionprophylactic volume expansion not usefulnimodipine 60 mg q4h x 14 daysrelative risk of stroke reduced 0.69 (0.58-0.84)Probably neuroprotection rather than a vascular effectnicardipine 0.075 mg/kg/hr is probably equivalent

Stroke 2000

Critical care issues: vasospasm and delayed ischemic damageManagementvolume expansionrarely achievedinduced hypertensioncardiac output augmentationdobutamine or milrinoneintra-aortic balloon pumpangioplastyverapamil or nicardipine (no longer use papaverine)intrathecal or intraventricular NO donors

Lancet 2012

Cerebral salt wasting: pathophysiologyvolume depletion puts SAH patients at risk for stroke from vasospasmWijdicks et al (1985) showed that volume restriction (as one would do for patients with SIADH) doubled the rates of stroke and death attributable to vasospasm

Critical care issues: neurogenic pulmonary edemaSymptomatic pulmonary edema occurs in about 20% of SAH patientsdetectable oxygenation abnormalities occur in 80%Potential mechanisms:hypersympathetic statecardiogenic pulmonary edemaneurogenic pulmonary edemaManagement

Seizures in SAH patientsabout 6% of patients suffer a seizure at the time of the hemorrhagedistinction between a convulsion and decerebrate posturing may be difficult postoperative seizures occur in about 1.5% of patients despite anticonvulsant prophylaxis remember to consider other causes of seizures (e.g., alcohol withdrawal)

Seizures in SAH patientspatients developing delayed ischemia may seize following reperfusion by angioplastylate seizures occur in about 3% of patients

SAH prognosisSudden death prior to medical attention in about 20%Of the remainder, with early surgery58% regained premorbid level of functionas high as 67% in some centers9% moderately disabled2% vegetative26% dead

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