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