Management of your patient.
Now, those individuals that you suspect
or possibly predisposing factors
such as Ehlers-Danlos,
always keep in mind, well,
what’s going on with my
anterior portion of
the circle of Willis?
Patients suspected of having SAH
should have of course a
non-contrast CT of the head.
4% of CT scans are
And if the CT scan is negative, then
you get into a lumbar puncture.
Now, before I move on,
there’s a topic that we did earlier when we
looked at meningitis and then encephalitis,
and I very clearly delineated the
clinical differences between the two.
We spent extensive time on lumbar puncture
and what you can expect in your
different findings in your CSF.
And at that time, we talked about HSV
encephalitis or meningoencephalitis.
And at that point, I told you
that if there is damage to brain,
there’s every possibility that
you might find RBCs in your CSF.
Now, let me ask you a question.
And I have subarachnoid hemorrhage,
and you know for a fact that the cerebrospinal
fluid actually circulates where?
Of course, subarachnoid space.
So now, say that there’s
actual hemorrhage there.
No matter how many samplings
that you would take
because what you’re going to measure for
here obviously is going to be what?
Is it glucose?
Not the obvious one.
Is it protein?
Not the obvious one.
Is it hemorrhage, please?
So what’s the obvious count
that you’re going to look for?
Are we clear?
This is hemorrhage.
So use common sense in terms of your
clinical judgement and suspicion.
Now if there’s constant bleeding taking
place into, into, the subarachnoid space,
I don’t care how many
samples you’ve taken.
One through four, you’re going
to find RBC counts to be high
from the first to the fourth compared
to when it’s something like trauma
in which if there’s trauma,
there’s every possibility that the
RBC count might start dropping.
But subarachnoid hemorrhage, not the case.
You’ll continue having high RBC count.
Patients with positive CT scan or lumbar
puncture should have an angiogram.
You need to check out and confirm
what exactly is causing this
This is an important, important topic
of management of your patient.
There’s something called
a Hunt and Hess scale.
Asymptomatic or mild headache
Moderate to severe
headache, nuchal rigidity.
As we go through this, you’ll
notice that when we finally get to
scale of five, patient comatose.
Please know at this point as a general
concept that the Hunt and Hess scale
will be something that you
would expect to then scale
understanding as to how bad is my actual,
actual headache and hemorrhage and such.