subarachnoid hemorrage –eso guidelines for management

Dr.Abdulgafoor.M.T ;MDICU ,ALKHOR HOSPITAL

Incidence:9 per 100000(Japan &Finland 15-17)

Mortality:60% within 6 months with conservative treatment

One third die from rebleeding within 6 months

1.6 times higher in femalesMedian age of onset 50-60 years90%of aneurysms less than 10mm and

90% in ACA circulation

EPIDEMIOLOGY

Statement on Definition Ruptured intracranial aneurysm’ (RIA) Unruptured intracranial aneurysm’

(UIA); asymptomatic’ or ‘symptomatic’ A symptomatic UIA usually causes

brain nerve palsy or rarely can cause arterial embolism

Asymptomatic UIAs are usually found incidentally

DEFINITIONS BY ESO (EUROPEAN STROKE ORGANIZATION)

Hunt& Hess grading1.Asymptomatic, mild headache, slight nuchal rigidity2.Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy3.Drowsiness / confusion, mild focal neurologic deficit4.Stupor, moderate-severe hemiparesis5.Coma, decerebrate posturing

CLINICAL APPEARANCE &GRADING

grade

GCS Focal neurological deficit

1 15 Absent

2 13–14 Absent

3 13–14 Present

4 7–12 Present or absent

5 <7 Present or absent

WFNS(WORLD FEDERATION OF NEURO SURGEONS) GRADING

Grade(1) GCS 15 Grade(2) GCS 11 to 14; Grade(3) GCS 8 to10Grade (4) GCS 4 to 7; Grade (5) GCS 3.

PAASH(PROGNOSIS ON ADMISSION OF ANEURYSMAL SUBARACHNOID HEMORRHAGE)

GRADING

Better correlated with outcome than WFNS

FISCHER GRADING

Grade Appearance of hemorrhage

1 None evident

2 Less than 1 mm thick

3 More than 1 mm thick

4 Diffuse or none with intraventricular hemorrhage or parenchymal extension

 Modified by Claassen and coworkers, reflecting the additive risk from SAH size and accompanying Intraventricular hemorrhage  0 – none 1 - minimal SAH w/o IVH 2 - minimal SAH with IVH 3 - thick SAH w/o IVH 4 - thick SAH with IVH

Recommendation• It is recommended that the initial assessment of SAH patients,and therefore the grading of the clinical condition, is done by means of a scale based on the GCS• The PAASH scale performs slightly better than the WFNS scale, which has been used more often (Grade3 Level C)

RECOMMENDATION-GRADING

Patient factors:Age,Hypertension,High systolic BP,Alcohol consumption,smoking (for delayed cerebral ischemia)

Aneurysm factors:Size and site of Aneurysm

Disease associated:Rebleeding,Delayed cerebral ischemia,Hydrocephalus

Treatment associated:Aneurysm clipping or coiling

Complications due to prolonged bed rest.

PREDICTORS OF OUTCOME

STATEMENT-RISK FACTORS

10% in first degree relatives

5-8% in first or second degree

Family history of Aneurysm in 10%

Polycystic kidney disease is associated

RECOMMENDATION-SCREENING

CT is useful in the early period .Afterward redistribution and resorption of blood occurs.After 5 days of bleed CT can detect only 85% and after 2 weeks 30%

MRI with flair technology comparable to CT in the early period and superior in the late stage

Water clear CSF during LP rules out SAH within 2-3 weeks

Gold standard :Cerebral panangiography.(sensitivity 0.77-0.97 &Specificity0.87-1)

DIAGNOSIS

RECOMMENDATION-DIAGNOSIS

– Intensive continuous observation at least until occlusion of the aneurysm

– Continuous ECG monitoringHourly GCS, focal deficits, blood pressure and temperature at least every hour

MONITORING

Statement on Physical Management Avoid situations that increase intracranial pressure,

The patient should be kept in bed Antiemetic drugs, laxatives and analgesics should be considered before occlusion of the aneurysm (GCP)

STATEMENT-TREATMENT

Recommendation for Blood Glucose Management

Hyperglycemia over 10 mmol/l should be treated (GCP)Blood pressure ManagementStop antihypertensive medication that the

patient was usingDo not treat hypertension unless it is

extreme; BP limits to be set on an individual

basis,depending on age , pre-SAH BP and cardiac history;

systolic blood pressure should be kept below 180 mm Hg, only until coiling or clipping of ruptured aneurysm,

RECOMMENDATION-TREATMENT

RECOMMENDATION-TREATMENT

RECOMMENDATION-TREATMENT

RECOMMENDATION-TREATMENT

RECOMMENDATION-TREATMENT

RECOMMENDATION-TREATMENT

Sizure at onset 7% 10% Develop sizure in first few weeks Convulsive status epilepticus in 0.2% Nonconvulsive status epilepticus in comatose

patients 8% Continuous EEG –no improvement in outcome In one RCT outcome worst in 65% who received

prophylactic antiepileptics Vs 35% in those didn’t receive .

RECOMMENDATION-TREATMENT

First few hours 15% rebleeds24 hrs to 4 weeks:35-40% rebleedsAfter 4 weeks: 3% per yearCase fatality rate day 1:25-30%1 week :40-45%First Month:55-60%First Year:65%Five Year:65-70%12%Die before reaching hospital

OUTCOME

Included only aneurysms which can be clipped or coiled.

90%were good gradesMCA aneurysms underrepresentedAbsolute risk reduction of death and

disability after 1 year 6.9%(23.7% Vs 30.6%)

Reduction in relative 5 year mortality in favour of coiling

Retreatment more in coiling(17.4% Vs 3.8%)

For young patients below 40 years clipping better

ISAT STUDY

RECOMMENDATIONS-INTERVENTION

RECOMMENDATIONS-TREATMENT

HYDROCEPHALUS

RECOMMENDATION

RECOMMENDATION-TREATMENT

RECOMMENDATION-TREATMENT

Triple H therapy: can cause increased cerebral oedema, haemorrhagic transformation in areas of infarction , reversible leucencephalopathy , myocardial infarction and congestive heart failure.

SAH WITHOUT ANEURYSM

Asymptomatic incidental aneurysmSymptomatic aneurysmAneurysms in SAH patients(multiple

aneurysm)

UNRUPTURED ANEURYSM

RECOMMENDATION-UNRUPTURED INTRACRANIAL ANEURYSMS