management of poor grade sah

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Diapositiva 1

Management of Ruptured Cerebral Aneurysms with Poor Grade SAH (Grade IV and V) Prof . Dr. Lenidas M. Quintana Department of Neurosurgery School of Medicine Valparaso University - Chile

Management of Ruptured Cerebral Aneurysms with Poor Grade SAHTreated Ruptured Cerebral Aneurysms (%) 1990-2009 Total: 929 cases

Management of Ruptured Cerebral Aneurysms with Poor Grade SAH IV VCT 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

1Management of Ruptured Cerebral Aneurysms with Poor Grade SAHInitial 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 ICP monitoring 2 Manitol Comfort measures Hyperventilation Surgery3 EVD 4 as soon as possible

Management of Ruptured Cerebral Aneurysms with Poor Grade SAH 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

Management of Ruptured Cerebral Aneurysms with Poor Grade SAHTOTAL : 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

Management of Ruptured Cerebral Aneurysms with Poor Grade SAHTIMING 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%)

Management of Ruptured Cerebral Aneurysms with Poor Grade SAHCompare brain edema.. no or slight..mild to severe parenchymal fragility no..yes blood-hardness of clots easy to aspirate...difficult to aspirateLeft ICA- Ant choroidal An