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SAH:
what are the scoring systems for SAH? Why use one over the other?
there are dozens of scoring systems for SAH, the most commonly used ones are Hunt and Hess (HH), World federation Neuro Surgery (WFNS), PAASH (purely GCS scale) and fischer.
outline the WFNS grading scale.
primarily based on GCS, motor deficit is only used to distinguish b/w 2-3 that are both GCS 13-14.
once GCS below 12, motor involvement doesn't matter.
what is the mortality rate of SAH?
how does it relate to the grade on admission?
What is the rebreeding rate and the risk of a re-bleed?
overall mortality rate of 50%
this includes 15% who die pre hospital arrival.
% survival per grade is roughly 70%, 60%, 50%, 20%, 10% for grade 1 - 5
re bleeding rate:
highest risk in 1st 24 hours (4%). then 1% per day ongoing.
60% risk of death with any rebleed.
what investigations are used in the diagnosis of SAH? what is the indication for each test?
outline the issues in SAH management?
1 - initial resus, stabilisiation and management with unsecured aneurysm.
2 - securing the aneurysm.
3 - delayed cerebral ischaemia (vasospasm)
4 - hydrocephalus
5 - seizures
6 - systemic complications.
outline the initial management of SAH until the time of securing the aneurysm?
ABC's.
intubate as appropriate for GCS.
aim for "normal" PaO2, PCO2, BSL, temp.
CVS
aim for "normal" BP. hypertension (SBP >160) risks rebleeding. hypotension (SBP < 100) risks cerebral ischaemia.
ECG - frequent arrythmia's, ECG changes. treat conservatively
Fluid:
euvolemia, frequently get electrolyte abnormalities.
outline the methods for securing the aneurysm?
what is the evidence for which technique to use?
when should the aneurysm be secured??
aneurysm can be either clipped (under GA with craniotomy in theatre) or coiled (under GA in lab).
ISAT = largest trail comparing the 2 methods, primary outcome was death and disability/dependence.
Coiling was better= 24% vs 31% death/dependence. only side note was that coiling gives slightly greater rate of delayed re-bleeding but still over all better.
Therefore: now all aneurysm are coiled unless anatomically to difficult (<10%).
When: earlier the better. <72 hours. used to wait till about 7 days, studies now show earlier the better.
what is delayed neurological decline (DND)?
is it the same thing as vasospasm?
DND is the major cause of death and disability after a SAH.
DND is any decline in neurological function after the bleed has been stabilised.
vasospasm is one cause of this, also sezires, hydrocephalus, cerebral odema, electrolytes, sepsis.
when does vasospasm occur?
what are the signs?
how is it diagnosed?
if they have new symptoms, do they need to be scanned?
What are the treatment options for vasospasm?
1 - Nimidopine
2 - Triple H therapy.
3 - endovascular treatments.
4 - NOT considered at this time:
anti coagulant, anti platelet, Mg, statins, temp.
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