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1 Aneurysms and SAH

2 Spontaneous SAH : : Ruptured intracerebral aneurysms( ): 75-80% Cerebral AVMs ( ( ):4-5 5 % of cases Certain vasculitides ( )that invove the CNS Rarely due to tumor ( ( ) Cerebral artery dissection ( ( 離 ) Rupture of a small superficial artery Rupture of an infundibulum Dural sinus thrmbosis ( 塞 ) Spinal AVM ( ( ) Pretruncal nonaneurysm SAH Non cause can be determined in 14-22%

3 Hypertension ( ( ) Oral contraceptives ( ( ) Substance abuse : ( ( ) cigarette smoking, following cocaine abuse, alcohol abuse : controversial diurnal variations in blood pressure ( ( 異 ) Pregnancy and parturition ( ( 便 ) Slight increased risk during lumbar puncture ( ( 刺 ) Slight increased risk with advanced age ( ( )

4 不

5 流行 率 6-8 例 /10 / 年 Ratio of 裂 : 裂 aneurysm is 5:3 : 5:6 年 Peak age ( ( 年 ) for aneurysmal SAH : years 50 % of patients :warning symptoms( 狀 ) usually 6-20 days before SAH Headache ( ( )is lateralized in 30 % 1993 年 裂 年 女 女 2:3 2:3

6 : 狀 1 : 2 : 3 : 暈 4 : 5 : 6 : : 7 :

7 : A : : 95 % of cases if scanned within 48 hrs of SAH B if CT is negative : 刺 : most sensitive,xanthochromia, : cell count( 數 ) : RBC count usually >100,000 RBCs/mm³ protein :elevated due to blood breakdown products, glucose :normal or reduced C: cerebral angiography ( ( ) ) : Magnectic resonance angiography ( ( ): 86% for detecting intracranial aneurysms >3 mm diameter CT angiography ( ): sensitivity ( ( 度 ) of 95 % and specificity( 異 ) ) of 83 % in detecting aneurysms a small as 2.2 mm

8 Grading SAH ( ( ) Grade 0: 0 Grade 1: 1 狀,, Grade 1a:, ) Grade 2: 2 度 -,, Grade 3, 不, Grade 4, 度 度 力, Grade 5 度 度,

9 Prognosis ( ) Grade (Hunt & Hess) Mortality(%) I 1 II 5 III 19 IV 42 V 77 Total 18

10 Grade Description Fischer scale : No clot seen on CT scan: (<1mm thickness): (>1mm thickness) 4,

11 Etiology: Congenital predisposition: ( ( e.g. defect in the muscular layer of the arterial wall,referred to as a medial gap medial gap ) Atherosclerotic or hypertensive Embolic :as in atrial myxoma : Infectious : Traumatic : : Associated with other condition

12 Conditions associated with aneurysms 1 :autosomal dominant polycystic kidney disease : 2 Fibromuscular dysplasia 3 AVM including moyamoya disease 4 connective tissue disorder : Ehlers-Danlos IV, Marfan s syndrome 5 : : 2 r more relative,third degree or closer 6 coarctation of the aorta 7 Osler-Weber Weber-Rendu syndrome 8 atherosclerosis 9 bacterial endocarditis

13 Location : : Saccular aneurysms 狀 : 流 力 Peripheral aneurysm : mycotic aneurysm : Fusiform aneurysms 狀 : 見

14 Saccular aneurysm location 狀 85-95% in carotid system ( ( ) 1 ACoA ( ( single most common ) :30 % 2 PComm : : 25% 3 MCA : : 20% 5-15% in posterior circulation ( ) 1 10% on basilar aretery : : basilar biurcation :most common 2 5% on vertebral aretery:va-pica junction - is most % multiple aneurysms:

15 1 SAH : : 2 ICH : : 20-40% ( more common with aneurysms distal to the circle of wills e.g MCA aneurysms ) 3 IVH : : 13-28% 4 subdural blood :2 :2-5%

16 10-15% 15% 療 率 10 %, 率 : 45% ( 32-67%) Rebleeding ( ),, the risk ( ( ):15-20% within 2 weeks Vasospasm ( ( ) ) kills 7 %, 7 7 % 30 % of survivor ( ( ) 度 Patient > 70 years

17 Treatment options of aneurysms 療 1 condition of patient : : 2 anatomy of the aneurysm 3 ability of surgeon 力 endovascular procedure 療

18 ( ) 療 1. 率 3~4%(24 3~4%(24 ) 1~2% 1~2% 3 年 率 3% 3% 2. 不 來 ( ( level of evidence to grade B ) ) 3.Antifibrinolytic therapy 來 / ( ( level of evidence to grade A ) ) 類 療 率

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20 Timming of aneurysm surgery Early surgery (<48-96hrs ) 1 降 率 2 易 療 3 Late surgery : ( days post SAH )

21 Conclusions : : 論 Insufficient class 1 data to make firm conclusion 力 1 流 2 療 3 early surgery delayed surgery 臨 early surgery 4 wrapping coating coating 不

22 Endovascular therapy : 療 Guglielmi Detachable Coils 1 to promote thrombosis of the aneurysmal sac to prevent bleeding 2 to reduce symptoms of mass effect 塞 1 2 療 3 狀 療 4 裂 3mm 3mm 5 裂 不 裂 3mm 療 不 療

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24 裂 理 unrupture aneurysm 裂 :UIA Estamate for UIA: 1% per year Risk of bleeding : multiple (6.8%) higher with single aneurysm (2.3% ) Aneurysm size : annunal risk of rupture <10 mm 0.05% > 10 mm :1 % giant aneurysm >2.5 cm : 6% in the first year C: for cavernous carotid aneurysms : the risk is low

25 裂 臨 不

26 : rebleeding : : 4% : 1.5%,15-20%, 50% 六, 年 3 %, 年 率 2 % 理 1: 2: 塞 : endovascular

27 Vasospasm 1 non-localizing findings: 狀, 識, 不, 狀 2 focal neurologic signs: 狀 狀 狀 Incidence and severity 率 度 Radiographic cerebral vasospasms : : 30-70% 狀 %, 7 % of SAH patients,

28 Diagnosis of cerebral vasospasm Vasospasm :Time course of vasospasm : : : days Defictit appropriate to involved arteries Rule-out other causes of deterioration,, : trasncranial doppler CBF studies SPEC, cerebral angiography

29 療 ( )Hypertension/hypervolemia/hemodilution (triple H H 療 ) 來 療 ( ( level of evidence to grade C ) ) )Nimodipine( 離 ) 連 降 ( level of evidence to grade A ) ( ) Transluminal angioplasty ( ) fibrinolysis antioxidant antioxidant anti- inflammatory ( ( level of evidence to grade C ) )

30 Seizure ( ) 裂 率 % 27.5% ( ( level of evidence to grade C ) ( ) 不 (level of evidence to grade C ) )

31 Hyponatremia ( ) 療 不 ( ) 了 volume status 量 CVP pulmonary capillary wedge pressure fluid balance 來 ( ) cerebral salt wasting syndrome SIADS

32 Hydrocephalus ( ) 20% 20% 流 ( ) 狀 流來 狀

33 Admitting orders 1 admit to ICU ( monitored bed ) 2 VS with GCS check q1h hr 3 : 30 度 4 nursing : : 理 A strict I s and O s O s : I/O B daily weights : 量 C knee high TED hose D indwelling Foley cather if patient lethargic, incontinent or unstable to void in urinal or bedpan 尿

34 5 diet A if preparing for early surgery NPO B if not considering for early surgery on diet 6 IV fluid : NS+20 Meq kcl/l at 2ml/kg/hr 7 medications ( avoid IM medications to reduce Pain ) A : prophylatic anticonvulsants :dilantin: B: sedations ( not overdose ): propofol, codein, phenobabrital C:analgesics fentanyl codeine ( avoid demerol lower seizure threshold )

35 D dexamethasone : 類 E: stool softer : : 便 F: anti-emetics : G: calcium channel blocker : nimodipine 60 mg q4h within 96hrs of SAH H: H2-blocker or proton pump inhibitors I: this agents impair coagulation and are contraindicated : ASA, dextran, heparin, and repeated administation of hetastarch

36 8 oxygenaation A : : O2 2L per NC PRN 度 B: for normocarbia po2 >100 mmhg 9 : : SBP mmhg by cuff is a guideline with unclipped aneurysm 10 Labs : A ABG eletrolyte CBC PT/APTT on admission B: ABG eletrolyte CBC q day C: serum and urine osmolarity if urine output high or low D: follow Hct ( for assesses viscosity ) E: CXR : daily until stable : F: 勒