management of subarachnoid hemorrhage gregory w balturshot, m.d. central ohio neurological surgeons...
TRANSCRIPT
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Management of Subarachnoid HemorrhageGregory W Balturshot, M.D.
Central Ohio Neurological SurgeonsMay 24, 2013
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Introduction
• Risk factors - hypertension, smoking, cocaine, female gender, age >50
• Genetic risk factors - Moya Moya, Ehlers-Danlos, PCKD, Marfan’s, fibrimuscular dysplasia
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Clinical Presentation
• 80% describe the sudden onset of worst headache on my life
• 20% experience ‘sentinal headache’ 2-8 weeks before SAH
• other symptoms include photophobia, nausea and vomiting, seizures, loss of consciousness
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Hunt Hess Scale
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Fisher Grade
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Diagnosis• Noncontrast CT - sensitivity 92-95%
• Lumbar Puncture - Xanthrochromia may take 12 hrs to appear after initial SAH. differentiates from a ‘traumatic tap’
• MRI/MRA - sensitivity 55-93% for aneurysms >5mm it is 85-100%
• CTA - 77-100% and 85-100%. Additional information such as wall calcification, intraluminal thrombus, relationship to the clinoids
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Gold standard is angiogram
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Initial Critical Care Management
• Stablization of systemic oxygenation/hemodynamics
• ICP control
• BP control
• Seizure prophylaxis
• Prevention of aneurysm rebleeding (9-17% within 72hrs)
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Clip vs Coil• ISAT - International subarachnoid
aneurysm trial
• 2134 good grade patients with <10 mm aneurysms in the anterior circulation were randomized to clipping or coiling.
• Death and dependency @ 1 yr 23.5% vs 30.9%
• Rebleeding rates?
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Clip vs Coil
• TEAM approach
• Factors include the clinical state of the patient, anatomic location, neck to dome ratio (wide neck), hematoma with mass effect
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