Podcast
Questions and Answers
What is the primary goal of blood pressure control before coiling or clipping an aneurysm?
Which intervention is indicated for a patient with intraventricular hemorrhage and a high Hunt-Hess score?
What medication is commonly used for the prevention/treatment of vasospasm after a subarachnoid hemorrhage?
In the event of rebleeding, which of the following temporary measures is NOT appropriate?
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Which factors should influence the decision between coiling and clipping an aneurysm?
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What is a common location for aneurysms to occur?
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Which type of aneurysm is characterized by asymmetrical ballooning of the blood vessel?
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What factor contributes to increased stress on cerebral vessel walls leading to aneurysms?
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What symptom is often described as the worst headache of one's life in SAH patients?
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Which diagnostic method is primarily used to identify blood in the cerebral sulci and ventricles?
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Which lifestyle factor is NOT identified as a contributing factor to subarachnoid hemorrhage?
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What is one of the clinical features of increased intracranial pressure?
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What triggers can lead to the rupture of an aneurysm?
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Study Notes
Subarachnoid Hemorrhage (SAH)
- A hemorrhage of the cerebral vessel, primarily the circle of Willis, into the subarachnoid space.
Etiology
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Traumatic Causes:
- Blunt force trauma
- Penetrating trauma
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Non-Traumatic Causes:
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Aneurysmal Causes:
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Types of Aneurysms:
- Saccular (Berry) Aneurysm: Asymmetric ballooning of the vessel
- Fusiform (Dolichoectatic) Aneurysm: Symmetrical dilation of the vessel
- Pseudoaneurysm: Dissection of the vessel creating a false aneurysm
- Mycotic Aneurysm: Infected aneurysm containing infectious material
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Contributing Factors:
- Hypertension: Increases stress on the vessel wall
- Sympathomimetics: Cocaine, Methamphetamines
- Smoking: Nicotine
- Ethanol: Alcohol use
- Oral Contraceptives/Pregnancy: Hormonal changes
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Types of Aneurysms:
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Genetic Causes:
- Connective Tissue Defects: Marfan syndrome, Ehlers-Danlos syndrome, polycystic kidney disease
- Abnormal Growth/Dysplasia: Fibromuscular dysplasia
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Infective Causes:
- Infective Endocarditis: Vegetations on valves release infective materials, leading to vessel wall degradation.
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Aneurysmal Causes:
Pathophysiology
- Stress on the vessel wall leads to weakening, dilation, and eventual rupture.
- Genetic defects and infections increase susceptibility to aneurysm formation and rupture.
Common Locations for Aneurysms
- Anterior Communicating Artery: 30%
- Posterior Communicating Artery: 25%
- MCA Bifurcation: 20%
- ICA Terminus: 7.5%
- Basilar Tip: 7%
- Anterior Cerebral Artery: 4%
- PICA: 3.5%
Triggers for Rupture
- Acute rise in blood pressure
- Painful stimulus
- Anger fits
Clinical Features
- Headache: "Worst headache of their life" or "thunderclap headache"
- Meningeal Signs: Photophobia, neck stiffness, positive Kernig's and Brudzinski's signs
- Increased Intracranial Pressure (ICP): Nausea, vomiting, cranial nerve deficits, posturing, Cushing's triad (high blood pressure, low heart rate, irregular respirations)
- Focal Deficits: Stroke symptoms
Hunt and Hess Score
- Asymptomatic/Mild Headache: Score 1
- Moderate/Severe Headache with Cranial Nerve Deficits: Score 2
- Lethargy, Confusion, Focal Deficits: Score 3
- Stupor, Early Posturing: Score 4
- Comatose, Decerebrate Posturing: Score 5
Diagnostics
- Non-Contrast CT Scan: Identifies blood in sulci, cisterns, and ventricles and hydrocephalus.
- Modified Fischer Score: Determines risk of vasospasm based on CT findings.
- CT Angiogram: Identifies aneurysms and reversible cerebral vasoconstriction syndrome.
- Digital Subtraction Angiogram: Gold standard for visualizing vessels.
- Lumbar Puncture: Identifies blood or xanthochromia in CSF when CT is inconclusive.
Treatment
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Initial Management:
- Airway, Breathing, Circulation (ABC): Secure airway, manage ICP, and control blood pressure.
- External Ventricular Drain (EVD): Indicated for high Hunt-Hess score, intraventricular hemorrhage, and hydrocephalus.
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Blood Pressure Control:
- Pre-Coiling/Clipping Goal: Systolic BP < 160 mm Hg.
- Medications: Nicardipine, labetalol, hydralazine, enalapril.
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Securing the Aneurysm:
- Coiling or Clipping: Must be done within 24 hours. Decision based on age, aneurysm neck size, hemodynamic stability, and location.
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Managing Complications:
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Rebleeding:
- Temporary Measures: Aminocaproic acid, tranexamic acid, cryoprecipitate, platelet transfusion.
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Vasospasm:
- Prevention/Treatment: Nimodipine, induced hypertension, intra-arterial dilators (verapamil, milrinone).
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Other Complications:
- Seizures: Anti-epileptic medications
- Pyrexia: Cooling measures (cooling blankets, arctic sun, ZOLL catheter, cold infusions) and anti-shivering medications (magnesium, buspirone, bromocriptine, propofol, opioids)
- Cerebral Salt Wasting: Fludrocortisone, normal saline infusions, 3% hypertonic saline infusions, salt tablets.
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Rebleeding:
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Description
This quiz covers the fundamentals of subarachnoid hemorrhage (SAH), including its etiology, traumatic and non-traumatic causes, and types of aneurysms. Learn the contributing factors and genetic causes associated with SAH. Perfect for healthcare students or anyone interested in neurology.
