00:00
Management: Clip or coil once they identified the aneurysm, hydrocephalus is a possibility and
by this you're going to then drain out the fluid intraventricular catheter. However, as soon
as that happens you're always worried about what please? Infections. Vasospasms occur in
30% of patients usually 4-14 days after symptom onset and up to 21 days later. Vasospasms
can cause cerebral ischemia and contribute significantly to the morbidity and mortality of a
person with a subarachnoid hemorrhage. They appear to be related to the release of
spasmogenic substances from lysed blood. To prevent and treat vasospasms, give nimodipine
which is a calcium channel blocker, but also offers neuroprotective effects by some other
unknown mechanisms. Hypertension is induced with vasopressors to maintain cerebral
perfusion and euvolemia is maintained with crystalloids or colloids. An external ventricular
drainage catheter is placed if there is elevated intracranial pressure or if the ventricle is
enlarged indicating hydrocephalus. Continuing our discussion of subarachnoid hemorrhage,
let's officially enter the topic itself. We just came off our discussion of aneurysms and if that
aneurysm is to then get large enough, it ruptures in this case with the berry aneurysm that
we referred to. You are then going to bleed into your subarachnoid space and perhaps even
then bleed on to your intraparenchymal type of hemorrhage. The complications here, as you
know, would be the worst headache that he/she has experienced called "thunderclap
headache," meningismus type of symptoms, and altered mental status. On CT, you can then
expect to see the type of hemorrhage that you see here. The complications that you're
worried about as we had mentioned earlier, if you peak approximately 3 weeks or 21 days
into your subarachnoid hemorrhage, you want to try to manage your vasospasms and there
we refer to our calcium channel blocker nimodipine or you are now also having issues with
properly draining your cerebrospinal fluid resulting in hydrocephalus and then increase
intracranial pressure could be then managed with drainage maybe perhaps with intraventricular
type of catheter. Summary. Risk factors: Age, female gender, African American race, most
likely due to hypertension, smoking, stimulants, alcohol. Preventive medicine: Remember, if
your patient you know is predisposed to developing an aneurysm, usually that's a 5th decade
of life. Management of unruptured aneurysm, 1% of general population, any risk of SAH, is
1-2% is related to aneurysm size. Risk factors for rupture of unruptured cerebral aneurysms
are namely larger size, location and the posterior circulation, and history of previous SAH.
03:13
Signs and symptoms: We talked about the headache, it could be loss of consciousness. Think
of it as being like a space occupying lesion. Differential diagnoses: At some point, we have
discussed cluster headaches, migraines, and meningitis are all differential diagnoses when
you're dealing with subarachnoid hemorrhage. Acute and post acute diagnostic work-up: CT
scan, we did a lumbar puncture, we discussed the tubes that you would find, for example,
because you're continuously introducing blood into subarachnoid space. No matter how many
samples you take, for RBC count it will always be pretty much elevated between 1 and 4.
03:56
Angiogram, you want to check out what cause the subarachnoid hemorrhage. And transcranial
Dopplers as well could help you. In other words, ultrasound. The management here will be
clipping and if we talk about coiling of aneurysm. For the prevention and treatment of
vasospasm, administer nimodipine, induce hypertension with vasopressors to maintain
cerebral perfusion and maintain euvolemia with crystalloids or colloids. If the intracranial
pressure becomes elevated or if there is evidence of hydrocephalus as indicated by enlarged
ventricles, then an external ventricular drainage catheter must be inserted.