TC13 03 Schmutzhard PDF
TC13 03 Schmutzhard PDF
TC13 03 Schmutzhard PDF
Teaching Course 13
Email: [email protected]
Conflict of interest: The author received research grants and speaker's
honoraria from Actelion and Edge.
Introduction
with an overall mortality of up to 50% and 25% dying within the first 24
(at the best within 6 hours) is highly reliable for diagnosis. Management of
delayed.
outcome.
Epidemiology
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Pathophysiology and Etiology of (SAH and) Vasospasm/DIND/DCI
Risk factors for aneurysm rupture, i.e. aSAH, include a family history of
alcohol abuse.
weeks, most commonly not before day 3 and rarely after day14 after the
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deemed necessary. Continuing cardiac monitoring is vital to evaluate for
Blood pressure control may be required, though the optimal target is not
initial SBP at less than 160 mm Hg. Cerebral perfusion pressure (CPP =
medications).
recommends use of these agents for less than 72 hours only if definitive
aneurysm treatment (i.e. securing the aneurysm) is delayed and there are
early as possible (at the best within <24 hours after the bleeding) has
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The two primary approaches for aneurysm repair include microvascular
all (most) SAH patients at the earliest possible point of time (ideally < 6,
when compared with clipping, though not all patients and/or aneurysms
complications of SAH
the CSF. Vasospasm may be present without any signs and symptoms (in
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may be needed for ICP control with cerebral edema, if other measures,
Evaluation of Vasospasm/DIND/DCI
Since in the majority of poor grade SAH patients, who are admitted to a
Neurocritical Care Unit and – after securing the aneurysm – are deeply
sonography did not fulfill its promises in recognizing early and potentially
daily use, if the examiner is always the same neuro-intensivist and well
familiar with this technique, the critical values being an increase in the
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In comatose, deeply analgosedated poor grade SAH patients the following
epilepticus,
assumed toherald very early the increased danger and risk of brain
tissue ischemia
support its use; a Cochrane review demonstrated a risk ratio of 0.67 (95%
i.e. thereby allowing for most precise dosing and modulating its major
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and, thus, ICU management. Magnesium sulfate IV has not demonstrated
cerebral perfusion, i.e. CPP. However, it has been shown that in the
abandoned.
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efficacy, case reports suggest a prolonged intraarterial application of,
temperature management
Prognosis of SAH
Mortality/Morbidity:
Close to 15% of patients will die before they reach the hospital, with 25%
dying within 24 hours and 45% of patients dying within 30 days. Morbidity
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Further Reading and References:
• Blok KM, Rinkel GJ, Majoie CB, et al. CT within 6 hours of headache onset
to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology
2015;84: 1927–32.
• Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al. Critical care
management of patients following aneurysmal subarachnoid hemorrhage:
recommendations from the Neurocritical Care Society’s Multidisciplinary
Consensus Conference. Neurocrit Care 2011;15(2):211–40.
• Dorhout Mees SM, Rinkel GJ, Feigin VL, et al. Calcium antagonists for
aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev
2007;(3):CD000277. 124. Pickard JD, Murray GD, Illingworth R, et al.
Effect of oral nimodipine on cerebral infarction and outcome after
subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ
1989;298(6674):636–42.
• Dubosh NM, Bellolio MF, Rabinstein AA, et al. Sensitivity of early brain
computed tomography to exclude aneurysmal subarachnoid hemorrhage: a
systematic review and meta-analysis. Stroke 2016 Mar;47(3):750–5.
• Guo J, Shi Z, Yang K, et al. Endothelin receptor antagonists for
subarachnoid hemorrhage. Cochrane Database Syst Rev
2012;(9):CD008354.
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• Macdonald RL, Higashida RT, Keller E, et al. Clazosentan, an endothelin
receptor antagonist, in patients with aneurysmal subarachnoid
haemorrhage undergoing surgical clipping: a randomised, double-blind,
placebo-controlled phase 3 trial (CONSCIOUS-2). Lancet Neurol
2011;10:618.
• Rabinstein AA, Friedman JA, Weigand SD, et al. Predictors of cerebral
infarction in aneurysmal subarachnoid hemorrhage. Stroke
2004;35(8):1862–6.
• Roos Y. Antifibrinolytic treatment in subarachnoid hemorrhage: a
randomized placebo-controlled trial. STAR Study Group. Neurology
2000;54:77.
• Schiefecker AJ, Dietmann A, Beer R, Pfausler B, Lackner P, Kofler M,
Fischer M, Broessner G, Sohm F, Mulino M, Thomé C, Humpel C,
Schmutzhard E, Helbok R. Neuroinflammation is Associated with Brain
Extracellular TAU-Protein Release After Spontaneous Subarachnoid
Hemorrhage. Curr Drug Targets. 2017;18(12):1408-1416.
• Veldeman M, Hollig A, Stevanovic A, et al. Delayed cerebral ischaemia
prevention and treatment after aneurysmal subarachnoid haemorrhage. Br
J Anaesth 2016;117(1):17–40.
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