2. Introduction
Anatomy
Scoring systems
Anaesthetic consideration
Intervention
General intensive care mx
Prognosis
Conclusion
3. 1-6% of the populations
SAH in 8-10:100,000 persons per year
1-2% risk of haemorrhage for unruptured
aneurysms
85% of non traumatic SAH- Ruptured
intracranial aneurysm
Age 40-60
Female (60%)
4. Mortality 50%
25% dying before reaching hospital
1/3 of survivors dependent for care
Almost ½ will have cognitive impairment
6. endovascular
services
the volume of
SAH
type of facility in
which thepatient
is first evaluated
severity of initial
hemorrhage
age
sex
time to treatment
medical
comorbidities
size,
location in the
posterior
circulation
morphology
PATIENT ANEURYSM INSTITUTION
ISUIA- International Study Of Unruptured Intracranial aneurysm
13. GRAD
E
FEATURES MORBIDI
TY
MORTALI
TY
0 unruptured aneurysm 0-2% 0-2%
1 Asymptomatic, min. headache and sl.
nuchal rigidity
2-5 % 2%
2 Moderate to severe headache, nuchal
rigidity, but no neurologic deficit
other than
cranial nerve palsy
5-10% 7 %
3 Somnolence, confusion, medium focal
deficits
5-10% 25%
4 Stupor, hemiparesis medium or
severe,
possible early decerebrate rigidity,
vegetative disturbances
25-30% 25%
5 Deep coma, decerebrate rigidity,
moribund appearance
40-50% 30-40%
15. GRADE FINDINGS
1 No blood visualized
2 diffuse deposition or thin layer with all vertical
layers of blood (interhemispheric fissure, insular
cistern, ambient cistern) less than 1 mm thick
3 Localized clots and/or vertical layers of blood 1 mm
or greater in thickness
4 Diffuse or no subarachnoid blood, but with
intracerebral or intraventricular clots
16. CT scan (no contrast)
MRI with haemosiderin-sensitive sequences
LP
CT angiogram – identify cause of SAH
DSA –digital subtraction angiography
22. Loss of consciousness
Hydrocephalus
Vasospasm
Intracerebral & intraventricular haematomas
Cerebral oedema
23. International subarachnoid aneurysm trial (ISAT)
Multicentre randomized controlled trial
Clipping reserved for aneurysms not suitable for coiling
those with wide neck, MCA
Endovascular
coiling
Surgical clipping
Primary outcome
(risk of death or
dependence at
1yr)
23.7% 30.9%
Long term:
delayed
retreatment
higher lower
25. Good SAH grade
Near normal ICP
Less prone to develop
ischemia
More chance of
rupture
Can tolerate fall in BP
up to 30-35%
Can not tolerate
much fall in CBF:
don’t hyperventilate
Poor SAH grade
Raised ICP
Relatively protected
against rupture
More at risk of
ischemia
Can not tolerate
much fall in BP
Hyperventilation
improves CPP
26. 1. Minimizing the degree and duration of
intraoperative hypotension during aneurysm
surgery is probably indicated
(Class IIa, Level of Evidence B).
2. There are insufficient data on
pharmacological strategies and induced
hypertension during temporary vessel occlusion
to make specific recommendations, but there
are instances when their use may be considered
reasonable(Class IIb, Level of Evidence C).
3. Induced hypothermia during aneurysm surgery
may be a reasonable option in some cases but is
not routinely recommended (Class III, Level of
Evidence B).***IHAST trial 2005
27. Incidence
-Aneurysm leak: 6%
-Frank rupture: 13%
-Combined incidence: 19%
When does it occur?
-Before dissection (7%)
-During dissection (48%)
-During clip placement (45%)
Increases overall mortality & morbidity
Better prognosis if occurs after opening of dura
28. BP control
Pain & anxiety
Seizure prophylaxis
Vasospasm
Rebleeding
Glucose control
VTE
29. Rate of rebleeding:
4% during the first 24 hrs
1.5% per day
19% first 2 weeks
50% first 6 months
3% per year
Mortality ( 78% )
30. 13.5% of mortality & morbidity.
cerebral ischaemia & infarction
Rare in the first 72 hrs after SAH,
Peaks 5-7 days, resolves after 14 days
Angiographic vasospasm 40-60%
Symptoms in 20-30%
Aetiology
Vasoactive substances (free oxyHb)
Stimulation of Endothelin1& inhibition of Nitric Oxide
32. 1. Oral nimodipine is indicated to reduce poor outcome
related to aneurysmal SAH (Class I, Level of Evidence A).
2. Treatment of cerebral vasospasm begins with early management
of the ruptured aneurysm, and in most cases,maintaining normal
circulating blood volume and avoiding hypovolemia are probably
indicated (Class IIa, Level of Evidence B).
3. One reasonable approach to symptomatic cerebral vasospasm
is volume expansion, induction of hypertension,and hemodilution
(triple-H therapy) (Class IIa, Level of Evidence B).
4. Alternatively, cerebral angioplasty and/or selective intraarterial
vasodilator therapy may be reasonable after,together with, or in the
place of triple-H therapy, dependingon the clinical scenario (Class IIb,
Level of Evidence B).
35. larger aneurysm
posterior circulation
prev hx of SAH
inc age
smoker
aspect ratio( height and neck of aneurysm)
36. Early vs delay surgical
intervention(International Cooperative study on
the timing of aneurysm surgery (1990)
HHH tx
Anticonvulsant prophylaxis
Antifibrinolytic tx
Family screening( level C)
Optimal glucose level
Pyrexia
Statin tx
MG tx