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Management of Ruptured Cerebral Aneurysms with Poor Grade SAH (Grade IV and V)

Prof . Dr. Leónidas M. Quintana Department of Neurosurgery – School of Medicine Valparaíso University - Chile

Management of Ruptured Cerebral Aneurysms with Poor Grade SAH

Treated Ruptured Cerebral Aneurysms (%) 1990-2009 Total: 929 cases

22%

37%18%

14%9%

WFNS Grade at Admission (%)

Grade IV: 130 cases (14 %) Grade V: 84 cases ( 9 %)

Total poor grade SAH: 214 cases ( 23% )

I

II

III

IV

V


IV V

CT Scan at admission...... It makes the difference between the posterior management ( explained in the next slide) and prognosis

Pattern

1- Critical brain damage

2- Brain swelling and/or edema

3- Acute Hydrocephalus

4- Intracerebral Hematoma

2

3 4

1


Initial Medical Treatment1-ABC *Control blood gases- If GCS< 8 : Intubation *Controlled ventilation- avoid hypoxemia *CPP Management avoid hypotension (unclipped 120-150mmHg.Systolic blood pressure) ; adecuate Central Venous Pressure (6-12 cm

H2O)2-Sedation – Analgesics- if intubated = muscle relaxants3-Nimodipine 60mg q.4 hrs per NGT4-Phenytoin 1gr initial ; 100 mg q.8hrs per NGTIf GCS < 8: ICP Monitoring ; EVD or Spiegelberg system

HSS 1 ICP monitoring 2 Manitol Comfort measures Hyperventilation Surgery3 EVD 4 “as soon as possible”


TOTAL : 214 CASES IN POOR SAH GRADE After the anterior management ( slide 5)- Re-evaluation at 12-24 hours

No improvement : 75 cases Clinical improvement : 139 cases (35%) ( 65%)

Comfort measures Angiography

DIED DIRECT SURGERY


TOTAL : 214 CASES IN POOR SAH GRADE

IMPROVED 139 patients

Grade IV 114 patients ( 82%)Grade V 25 patients ( 18%)

NOT IMPROVED 75 patients(*)

Grade IV 16 patients ( 21 %)Grade V 59 patients ( 79 %)

(*)The majority of these patients had pattern 1 and 2 at the initial CT Scan


TIMING OF DIRECT OPERATION139 PATIENTS WITH CLIPPED ANEURYSMS

Before 48 hours 68 patients ( 49%)

Between 48-72 hours 49 patients (35%)

After 72 hours 22 patients (16%)


Compare brain edema……….. no or slight……………………..mild to severe parenchymal fragility no……………………………..yes blood-hardness of clots easy to aspirate……..………….difficult to aspirate

Left ICA- Ant choroidal An <24 hours Op. 96 hours Op.

TIMING OF SURGERY

Right MCA An

6 months follow up of 139 clipped aneurysms cases FUNCTIONAL STATEState I : return to normal life State II: return to life with mild limitationsState III: return to life with severe limitations or vegetative stateState IV: dead

114 patients Grade IV Global results

State I 41 patients ( 36%)State II 24 patients ( 21%) Good 57% State III 17 patients ( 15%)State IV 32 patients ( 28%) Bad 43%

25 patients Grade V

State I 6 patients ( 24 % )State II 4 patients ( 16 % ) Good 40 % State III 7 patients ( 28 % )State IV 8 patients ( 32 % ) Bad 60 %


Total Mortalityof Poor Grade SAH(n= 214 cases)

53,7%

Some considerations.........

• This paper shows that early and aggresive management , medical & surgical treatment, is better than late management, in poor grade SAH ( 53,7 vs. 90 % mortality)

• Early management courses until 48 hours after initial bleeding.• After that period is late management.

• Not all grade IV&V patients have the same “damage pattern”

• “Not all cases fall in the same bag”, as you can see in these images.....

Critical brain damage Brain swelling Acute Hydrocephalus Intracerebral Hematoma and/or edema


Management of Ruptured Cerebral Aneurysms- SAH Grade IV and VSome considerations , that can aid to improve complications.........

MCA aneurysm –short M1 bifurcation- Topical action of Nimodipine

Pre topical application Post topical application

Vasospasm

Some considerations , that can aid to improve complications.........

Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhagePaul Klimo Jr, John R. W. Kestle, Joel D. Mac Donald, Richard H. Schmidt. Department of Neurosurgery, University of Utah, Salt Lake City, Utah (J Neurosurg 100:215–224, 2004)

WE APPLY THE SAME CONCEPT WITH ON LAY SUBARACHNOID DRAINAGE

“The V ventricle”


Vasospasm

Aneurysmal Subarachnoid HemorrhageManagement of Complications

Hydrocephalus

1-Acute Hydrocephalus ( Obstructive ) ,should be treated with External Ventricular Drainage, in cases of progressive neurological deterioration.We should avoid complications as rebleeding and infections (dripping reservoir over 20mmHg from 0 point)

2-Chronic Hydrocephalus (Communicating), should be prevented with Fenestration of LaminaTerminalis, to decrease the shunting rate,the incidence of vasospasm and to have a better clinical outcome . If it fails….. VP shunt

FENESTRATION OF THE LAMINA TERMINALIS AS AVALUABLE ADJUNCT IN ANEURYSM SURGERY

Norberto Andaluz, Mario ZuccarelloThe Neuroscience Institute,Department of Neurosurgery,University of

Cincinnati College of Medicine(Neurosurgery 55:1050-1059, 2004)

Pre Op. 6hrs Post Op.

THANK YOU VERY MUCH !!!

Prof . Dr. Leonidas M. Quintana Department of Neurosurgery – School of Medicine Valparaíso University - Chile

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