Aneurysm presentation-- random clinical pearls

Diagnosis
1.  Of patients with the worst headache of their life, ten percent have aneurysms
2.  Sensitivity of LP to detect aneurysms decreases by seven percent per day
3.  CT-A removes need for catheter angiography in those with more than 5 rbc's
4.  SAH- aneurysmal peaks in April and September and nadirs in June and July
5.  Population prevalence of aneurysm in 2 %
Treatment
6.  **FENESTRATION OF LAMINA TERMINALIS IS EASY, DECREASES HYDROCEPHALUS INCIDENCE FROM 13 TO 2 PERCENT AND ALLOWS LUMBAR DRAINS
7.   EEG is a "pseudoexam " under anesthesia
8.  St Julien NSURG 2008  cardiopulmonary bypass without a chest incision (endovascular)allows fine control of BP and avoids circulatory arrest, hypothermia improves outcomes ( outcome of St Julien)  Grade 0 , 1 (1.5 %), 2 (6.2%), 3 (12.1%), 4 (17.4 %).  CP bypass is good for giant aneurysms
9.  Fisher scale stratifies the risk of vasospasm .  Grade 1: no blood   Grade 2:  vertical layer < 1mm
      Grade 3:    vertical layer > 1 mm, local clot     Grade 4:  ICH/IVH but minimal or no SAH. GRADE  THREE IS MAXIMAL RISK> GRADE FOUR.  Risk of vasospasm is 23 %.   With modified Fisher scale, vasospasm is greatest with grade 4.  About 20-30 % of vasospasms stroke.
10.  Risk of rebleed is 4 % in first 24 hours, then 1-2 % per day for 4 weeks.  Cumulative risk is 20 % at 2 weeks, 30 % at one month, 40 % at 6 months. Ventriculostomy which otherwise can be lifesaving also can precipitate a rebleed.
10.  Risk of rebleed is       

Hemorrhagic shock plus TBI no longer uniformly fatal

Combination is less lethal than formerly provided that CPP is maintained.  Treatment algorithm:  stop bleeding (factor 7), restore volume (whole blood, crystalloid), saline, plasma, platelets, pressors (phenylephrine, vasopressin, norepinephrine, DA), prophylactic phenytoin, for 7 days, treat fevers with tylenol, aggressive nutrition, use hemicraniectomy for impending herniation is efficacious, use GCS to communicate. 

Prehospital care:  avoid hypoxia-- give oxygen, avoid hypotension, hypertonic saline is good; mannitol only if intravascular volume can be maintained, generally avoid hyperventilation unless herniating. 

ICP monitor if GCS < 8 and abnormal CT scan.  Want ICP< 20, intervention threshold around 25.  ICP plateau or A waves are sine qua non of herniation.  These are best seen with changing sweep speed on monitor to minutes.  B waves last from 0.5 to 2 minutes and are associated with changing brain compliance not increased ICP.  C waves are ICP waves associated with respiration. 

Components of a "brain code" are 1) elevated HOB to 45 degrees   2)  HV to pCO2 around 35   3) mannitol .5 grams/kg   4) saline bullet (see    http://neurologyminutiae.blogspot.com/2010/04/saline-bullets-and-hypertonic-saline.html)   5) CSF  drainage

from lecture by Dr Ling

Vasospasm after traumatic brain injury

Unlike its better known couin that occurs after SAH, vasospasm after TBI follows a different time course of 10-21 days is often subclinical and is best treated with nicardipine and endovascular therapy.  It can be monitored with TCD. 

Source-- lecture Col. Geoffrey Ling , MD

Pearls on blood pressure, misc and hemorrhagic stroke care

1.  PET studies do  not support the concept of an ischemic penumbra, hence blood pressure control should be used judiciously (Schellinger et al, Stroke 2003)

2.  The occurrence of ICH is strongly related to prevailing blood pressure, however no definitive evidence exists that recurrent ICH in the acute setting relates to blood pressure or control thereof (Jauch et al. Stroke 2006)

3.  Intracranial hypertension is associated with a worse outcome

4.  Prior statin use is associated with decreased perihemorrhage edema and decreased 30 day mortality ; however this data is retrospective (Naval et al., 2 refs Neurocritical Care 2008)

5. The Stroke Council continues to advocate for 2-4 weeks of prophylactic antiepileptic therapy in patients with SICH and SAH

6.  Hematoma size (Stoke 1997, Brott et al) and growth (Davis et al, Neurology 2006)  are correlated with mortality

7.  The "spot sign" or contrast extravasation in CTA may identify patients at high risk of hematoma expansion

8.  ICH < 30 cc may benefit from intraclot alteplase

9.  MIS minimal invasive surgery is also considered under investigation although certain types of ICH do not benefit