NEUROLOGY + NEUROSURGERY

ResponseHyperdensity “location” consistent with acute bleed.
Extensive SAH
Intraventricular bleed (or no intraventricular blood) + location
Dilation of lateral horns mass effect from bleed causing hydrocephalus
Midline shift to L/R (+ ? severity/displacement)
Loss of gray/white differentiation - Oedema
No tonsilar herniation
No signs of trauma (soft tissue swelling or bony fracture)

ResponseRule out tool (like perc) not a scoring system. 100% sensitive during validation study.
Age >=40
Neck pain/stiffness
Witnessed LOC
Onset during exertion
Thunderclap headache
Limited flexion on examination
CT HEAD - Collapse, Thunderclap, Hurty neck, Exertional, Age ?40, Decreased flexion

ResponseSmoking
Htn
EtOH abuse
Family history

ResponseHeadache (thunderclap) - typically 25% of people with thunderclap HA have SAH
Onset during strenuous exercise
Neck pain
Neck stiffness
Photophobia
Transient or prolonged decrease in consciousness
Seizures
nausea/vomiting
Focal neurologic signs

ResponseDiagnosis: acute _________ bleed
Prognosis - most likely to be life ending event, if survived will have severe neurologic deficits
Patients wishes - any previously expressed wishes, ?values on independence
Plan - ceiling/goals of care discussion
Expected course of illness + disposition

ResponseCT brain ~98.5% sensitive, 99.5% specific for detecting SAH

Sensitivity for SAH
Reduced with increasing time after onset
Reduced in non consultant report
Reduced in small volume bleed

ResponseLP:
Pro

• Diagnose SAH with xanthochromia (red cell breakdown products - bilirubin and oxy-hemoglobin)
• Identify meningitis if differential

Con

• Invasive, not all centres have access to spectrophotometry for xanthchromia studies.
• Traumatic tap in ~15-20%, can be technically difficult if fat
• Perform 12 hours from onset, time consuming

CT angiogram
Pro

• diagnose aneurysm (Managable cause),
• Diagnose alternate cause for headache (eg: vertebral artery dissection, venous sinus thrombus)
• Non invasive

Con:

• Aneurysm rate ~1-2%, may be asymptomatic (incidental/unrelated).
• Radiation
• IV contrast required ? reaction

ResponseSigns of raised intracranial pressure - papilloedema, bradycardia/hypotension
GCS <14
Immunosuppression
Focal neurologic deficit
New onset seizure
CNS disease (mass lesion, AVM, etc)
Older age
Suspected SAH

ResponseAbsence of xanthchromia
Zero or few RBC’s (<5)

ResponseAirway protection

• Fentanyl premed prior to intubation
• Avoid ETT tube ties (obstructs venous return) - use tape
• Maintain CPP - metaraminol on standby

Neuroprotective measures

• pCO2 30-35
• pO2 >80
• Head up 30 degrees
• Normothermia
• Normoglycemia 6-10

Adequate sedation +/- paralysis

• Morphine + midazolam

Treat hypertension

• Invasive BP monitoring
• SBP <140 (?<160), NO permissive hypotension, MAP >80m or SBP 100-110
• Hydralazine 5mg aliquots to 20 mg, GTN/SNP titrated to endpoints (Some say not nitrates?. RNSH Labetalol, hydralazine, metoprolol)
• Metoprolol 2.5mg aliquots to HR

Expedite Neurosurgical review

• Early vs delayed clipping
• ICP monitoring
• EVD for monitoring/CZF draining if developing hydrocephalus

Monitor for vasospasm

• Nimodipine infusion 1mg/h titrate to 4mg/h (Or 60 mg QID)

Supportive cares

• IDC + hourly measures (Diabetes insipidus/SIADH)
• NGT if intubated
• Correct electrolyte abnormalities (aim sodium high normal)
• Coagulation abnormalities
• Maintenance fluids (isotonic)

Neurosurgical referral

Response3% saline 3 mL/kg (aim Na <155)
Mannitol 0.5 -1 g/kg (20%) solution

ResponseRe-bleeding
Seizure
Hydrocephalus
Hyponatraemia
Cerebral vasospasm
Hypoxia from pulmonary oedema

ResponseWFNS (world fedaration for Neurosurgical Societies) - clinical /5. (needed to describe this in one Q)

1. GCS 15
2. GCS 13-14 + no focal deficit
3. GCS 13-14 + focal deficit
4. GCS 7-12
5. GCS 3-6

Hunt and Hess - clinical/5 - (1=mild symptoms, 3= confused, 5= comatose)
WFNS and H+H basically 1=very mil, 5= catastrophic. Fill in the rest?
Fischer - radiologic /4.

ResponseNon cardiogenic pulmonary oedema
Bilateral symmetrical pulmonary infiltrates
Perihilar prominence
Alveolar in pattern

Managed with increased PEEP