Our Lady of Fatima University

NCM 107 B

Our Lady of Fatima University

Valenzuela City, College of Nursing

Case Study: Subarachnoid HemorrhageStudent: Estanislao, Carmela Marie J.NCM 107 (RLE) 4Y2-2A, 2nd SemesterClinical Instructor: Vanessa Umali, RN MAN

Jannuary 30, 2015Introduction

Subarachnoid hemorrhage is sudden bleeding into the subarachnoid space. The most common cause of spontaneous bleeding is a ruptured aneurysm. Symptoms include sudden, severe headache, usually with loss or impairment of consciousness. Secondary vasospasm (causing focal brain ischemia), meningismus, and hydrocephalus (causing persistent headache and obtundation) are common. Diagnosis is by CT or MRI; if neuroimaging is normal, diagnosis is by CSF analysis. Treatment is with supportive measures and neurosurgery or endovascular measures, preferably in a comprehensive stroke center.

Subarachnoid hemorrhage is bleeding between the arachnoid and pia mater. In general, head trauma is the most common cause, but traumatic subarachnoid hemorrhage is usually considered a separate disorder (seeTraumatic Brain Injury (TBI)). Spontaneous (primary) subarachnoid hemorrhage usually results from ruptured aneurysms. A congenital intracranial saccular or berry aneurysm is the cause in about 85% of patients. Bleeding may stop spontaneously. Aneurysmal hemorrhage may occur at any age but is most common from age 40 to 65. Less common causes are mycotic aneurysms, arteriovenous malformations, and bleeding disorders.

Headache is usually severe, peaking within seconds. Loss of consciousness may follow, usually immediately but sometimes not for several hours. Severe neurologic deficits may develop and become irreversible within minutes or a few hours. Sensorium may be impaired, and patients may become restless. Seizures are possible. Usually, the neck is not stiff initially unless the cerebellar tonsils herniate. However, within 24 h, chemical meningitis causes moderate to marked meningismus, vomiting, and sometimes bilateral extensor plantar responses. Heart or respiratory rate is often abnormal. Fever, continued headaches, and confusion are common during the first 5 to 10 days. Secondary hydrocephalus may cause headache, obtundation, and motor deficits that persist for weeks. Rebleeding may cause recurrent or new symptoms.

Usually non-contrast CT and, negative, lumbar puncture. Diagnosis is suggested by characteristic symptoms. Testing should proceed as rapidly as possible, before damage becomes irreversible. Noncontrast CT is>90% sensitive and is particularly sensitive if it is done within 6 h of symptom onset. MRI is comparably sensitive but less likely to be immediately available. False-negative results occur if volume of blood is small or if the patient is so anemic that blood is isodense with brain tissue. If subarachnoid hemorrhage is suspected clinically but not identified by neuroimaging or if neuroimaging is not immediately available, lumbar puncture is done (seeLumbar puncture (spinal tap)). Lumbar puncture is contraindicated if increased intracranial pressure is suspected because the sudden decrease in CSF pressure may lessen the tamponade of a clot on the ruptured aneurysm, causing further bleeding.

CSF findings suggesting subarachnoid hemorrhage include numerous RBCs, xanthochromia, and increased pressure. RBCs in CSF may also be caused by traumatic lumbar puncture. Traumatic lumbar puncture is suspected if the RBC count decreases in tubes of CSF drawn sequentially during the same lumbar puncture. About 6 h or more after a subarachnoid hemorrhage, RBCs become crenated and lyse, resulting in a xanthochromic CSF supernatant and visible crenated RBCs (noted during microscopic CSF examination); these findings usually indicate that subarachnoid hemorrhage preceded the lumbar puncture. If there is still doubt, hemorrhage should be assumed, or the lumbar puncture should be repeated in 8 to 12 h.

In patients with subarachnoid hemorrhage, conventional cerebral angiography is done as soon as possible after the initial bleeding episode; alternatives include magnetic resonance angiography and CT angiography. All 4 arteries (2 carotid and 2 vertebral arteries) should be injected because up to 20% of patients (mostly women) have multiple aneurysms.

On ECG, subarachnoid hemorrhage may cause ST-segment elevation or depression. It can cause syncope, mimicking MI. Other possible ECG abnormalities include prolongation of the QRS or QT intervals and peaking or deep, symmetric inversion of T waves.

About 35% of patients die after the first aneurysmal subarachnoid hemorrhage; another 15% die within a few weeks because of a subsequent rupture. After 6 mo, a 2nd rupture occurs at a rate of about 3%/yr. In general, prognosis is grave with an aneurysm, better with an arteriovenous malformation, and best when 4-vessel angiography does not detect a lesion, presumably because the bleeding source is small and has sealed itself. Among survivors, neurologic damage is common, even when treatment is optimal.Treatment in a comprehensive stroke center Nicardipinif mean arterial pressure is>130 mm Hg. Nimodipineto prevent vasospasm. Occlusion of causative aneurysms Patients with subarachnoid hemorrhage should be treated in a comprehensive stroke center whenever possible.

Hypertensionshould be treated only if mean arterial pressure is>130 mm Hg; euvolemia is maintained, and IVnicardipinis titrated as for intracerebral hemorrhage (seeIntracerebral Hemorrhage). Bed rest is mandatory. Restlessness and headache are treated symptomatically. Stool softeners are given to prevent constipation, which can lead to straining. Anticoagulants and antiplatelet drugs are contraindicated.

Vasospasmis prevented by givingnimodipine 60mg po q 4 h for 21 days to prevent vasospasm, but BP needs to be maintained in the desirable range (usually considered to be a mean arterial pressure of 70 to 130 mm Hg and a systolic pressure of 120 to 185 mm Hg). If clinical signs of acute hydrocephalus occur, ventricular drainage should be considered.

Learning Objectives

Upon completion of our affiliation here Armed Forces of the Philippines Medical CenterTo gain newinformation about the patients disease and its etiology, pathophysiology, clinical manifestations as well as the standard medical andnursing management so that wemay apply this newly-acquired knowledge to our patient as well as similar situations in the futurePatients Profile

Name: G.B

Age: 66 y/o

Civil Status: Married

Date Admitted: 03-01-2015

Time Admitted: 6:20 PM

Sex: Male

Religion: Catholic

Diagnosis: CVD probably infarct R, hypertensive cardio vascular diseasePast and Present Health HistoryCase of B.G 66y/o, male, residing at brgy. V.C. Few hours PTA L sided weakness, numbness body associated with seizure. The patient was diagnosed w/ CVD.Family History(+))Hypertension

(-) DM

(-) Allergy

Anatomy and PhysiologyMeningesThe meninges(they are serous membranes)are three layers of protective tissue called thedura mater,arachnoid mater, andpia mater meninges of the brain and spinal cord are continuous, being linked through the magnum foramen. Below is a simplified illustration of the meninges around the brain.Dura MaterMost superior of the layers it is tough and inflexible and forms several structures that separate the cranial cavity into compartments and protect the brain from displacement.

Arachnoid MaterMiddle layer of the meninges makes arachnoid villi,small protrusions through the dura mater into the venous sinuses of the brain, which allow CSF to exit the sub-arachnoid space and enter the bloodstream. Cerebrospinalfluid(CSF) flows under the arachnoid in the subarachnoid space.Pia MaterThe delicate innermost layer of themeninges a thin fibrous tissue that is impermeable to fluid which allows it to enclose CSF (cerebrospinal fluid). By containing CSF, pia works with the other meningeal layers to protect and cushion the brain. Allows blood vessels to pass through and nourish the brai

The perivascular space created between blood vessels and pia mater functions as a lymphatic system for the brain. Lines the brain down into itssulci(folds).Sulcusisa depressionon the cerebral cortex while. Gyrus ridge on the cerebral cortex.

The Spaces Between the Layers:Epidural Space Between the dura mater and the skull.Common location for hemorrhaging in the brain.

Subdural SpaceBetween the dura mater and the middle layer of the meninges, the arachnoid mater. When bleeding occurs, blood may collect here and push down on the lower layers of the meninges, possible causing brain damage.

Subarachanoid SpaceFrom the fourth ventricle, the cerebrospinal fluid passes into the subarachnoid space where it circulates around the outside of the brain and spinal cord and eventually makes its way to the superior sagittal sinus via the arachnoid granulations also called arachnoid villi. In the superior sagittal sinus, the cerebrospinal fluid is reabsorbed into the blood stream.

Cerebrospinal fluid (CSF) clear, saline bodily fluid that occupies the subarachnoid space and the ventricular system around and inside the brain. It is produced continuously at a steady rate and is essential for the normal functioning of the CNS.It acts as a cushion for the neuraxis, also bringing nutrients to the brain and spinal cord and removing waste from the system.Pathophysiology

Exam NameResultReference Range

Hemoglobin159 g/ L130 170

Hematocrit46.70 %40 54

RBC 5.94 10^6/ uL4 6

MCV78.60 fL86 110Low

MCH28.80 pg26 38

MCHC34.00 g/ dL31 37

WBC24.25 10^3/ uL4.5 10.5High

Diff Count

Nuet%86.8 %40.0 80.0High

Lymph%8.9 %20 40Low

Baso%0.2 %0 - 5

Mono%7.1 %0 12

Eo%0.1 %0 6

PLT375.00 10^3/ uL150 450

RDW-SD41.40 fL37 - 54

Diagnostic Exams HematologyCT Scan

Impression:

Acute Hemorrhage, Right Basal Ganglia with Subarachnoid Extension

Cerebral Edema

Physical Assessment

SKIN: (-) lesionHEENTS:

CHEST: symmetricalHEART: (-) murmurLUNGS: (-) retractionABDOMEN: (-)murmurGENITALIA: N/ARECTUM: N/AEXTREMITIES: peripheral pulses are equalNEUROLOGICAL: GCS 10 L sided weakness