Subarachnoid hemorrhage

Subarachnoid Hemorrhages

Subarachnoid Hemorrhage• Subarachnoid hemorrhage (SAH) is

bleeding into the subarachnoid space.

• SAH may occur spontaneously from an aneurysm or from head trauma.

• Mortality from SAH are very high (10% die before the hospital, 25% with 24 hours & 45% with 30 days) Stroke 1994;25(7)1342

Subarachnoid Hemorrhage

• Signs and Symptoms of a SAH:

• Headaches• Photophobia• Nausea & Vomiting• Seizures• Decreased LOC• Neurological Deficits• Stiff Neck• Seizures

Subarachnoid Hemorrhage• The Hunt & Hess Classification grades the severity SAH based

on the patient’s clinical condition:

Subarachnoid HemorrhageWhy are SAH so deadly?• Hydrocephalus • Rebleeding • Vasospasms & Delayed Cerebral Ischemia • Elevated ICP

First Hour First Day 30days0

1020304050

SAH MORTALITY RATES:

Subarachnoid HemorrhagesHYDROCEPHALUS:

• Hydrocephalus develops in 20 to 30% of SAH patients. Stroke 2009;40(3)994

• Communicating hydrocephalus, the type seen after SAH, occurs when CSF cannot be absorbed normally through the arachnoid villi.

Subarachnoid Hemorrhages REBLEEDING:

• 4% of patients rebleed in the first 6 hours.

• 20% of patient rebleed within 14 days.

• Rebleeding is catastrophic (80% mortality rate)

Subarachnoid HemorrhagesDELAYED CEREBRAL ISCHEMIA:

• Vasospasms occur in 40-60% of SAH patient.

• 20-30% of vasospasm patients develop delayed cerebral ischemia (DCI).

• Some patient develop DCI without vasospasm.

• Pathogenesis of vasospasm and DCI not fully understood.

Subarachnoid Hemorrhages

INTACRANIAL PRESSURE:

+ +80% 10 % 10%

• The skull is rigid and can not expand.• Volume = Brain (80%) + blood (10%) + CSF (10%).• Increased volume within the skull will increase the ICP.• Normal ICP is 10 – 20 mmHG• Cerebral edema, blood, and hydrocephalus may caused an elevated ICP

(<20mmHg)• Elevated ICP worsens outcomes

Subarachnoid HemorrhageLET’S REVIEW:

• SAH is bleeding into the subarachnoid space

• The Hunt & Hess Classification grades the degree of neurological deficits

• Grade I (mild deficits + mortality) → Grade V (severe deficits + mortality)

• SAH patients have a substantial mortality rate from hydrocephalus, rebleeding, increased ICP & delayed cerebral ischemia (vasospasms)

• Early, the risk of bleeding is higher. Later, the risk of vasospasms increases (see next slide).

Subarachnoid HemorrhageVasospasm 0 to 21 days

❶Vasospasm can develop up to 3 weeks.❷Highest prevalence between 7 and 21 days.❸Vasospasms may not cause neurological deficits.❹Pathogenesis of vasospasm is not fully understood.❺Delayed Cerebral Ischemia results in new neurological deficits.

Rebleeding 0 to 14 days

Highest risk in the first 6 hours

❶ Early surgical repair (day 1 to 3: clipping or coiling) reduces the risk of rebleeding.❷ Careful BP control reduces the risk of rebleeding.

Highest risk of vasospasm from 7 to 21 days


BASIC NURSING CARE:• VS Q1H• NVS as ordered• Temperature Q4H + PRN• Zero ICP Monitor Qshift + PRN• ICP + CPP Q1H + PRN• CSF Drainage Q1H• ABG Qshift + PRN• HOB 30degrees

Next, lets get more specific:

Subarachnoid HemorrhageMANAGEMENT OF A SAH:

❶Hydrocephalus Management❷Blood Pressure Control❸Early Surgical Management (clipping or coiling)❹Hypertensive Therapy❺Nimodipine Therapy❻Temperature Control❼Seizure Control❽ ICP Management❾Pain / Nausea Control

Subarachnoid Hemorrhage① HYDROCEPHALUS:

• Hydrocephalus is a frequent complication of a SAH.

• EVD are inserted to drain excessive CSF and to monitor ICP.

• Initially, CSF is bright red but slowly becomes yellow (xanthochromia).

• Nursing Care:• NVS as ordered• Q1H ICP Monitoring• Q1H CCP Monitoring• Q1H CSF Drainage Output• Qshift Zero EVD• Ensure collection chamber is at the

correct height (cmH20 or mmHg)• Level EVD PRN

Subarachnoid Hemorrhage② BLOOD PRESSURE CONTROL:

• BP should be kept between 120 to 160mmHg

• BP goal set by Neurosurgery Team

• Hypertension increases the risk of rebleeding Stroke 2009;43:1711-37

• Aggressive BP management (too low) increases the risk of infraction Stroke 2012;43: 1711-37

• Nursing Care:• NVS• Q1H BP (and PRN)• Minimize stimulation• Prevent emesis• Pain Control• Medication PRN

Subarachnoid Hemorrhage③ SURGICAL MANAGEMENT:

• Typically, the aneurysm is secured within the first 3 days (coiling or clipping depending upon type of aneurysm and location).

• Reduces the risk of rebleeding.

• Allows more aggressive management of vasospasm and delayed cerebral ischemia.

Subarachnoid Hemorrhage④ HYPERTENSIVE THERAPY:

• Hypertensive therapy is utilized to combat vasospasms.

• Vasospasm can cause cerebral ischemia and neurological deficits.

• Levophed (as well as Milrinone) is used to increase BP which preserve cerebral blood flow and prevent ischemia.

• In extreme cases, endovascular rescue therapies (balloon dilation and intra-arterial medications) may be attempted.

• Nursing Care:• NVS as ordered• Ensure BP parameters are achieved


⑤ NIMODIPINE THERAPY:

• Nimodipine, a calcium channel blocker used to help prevent vasospasms induced cerebral ischemia

• Mechanism of action of Nimodipine not fully understood. N England Journal of Medicine 1983;308:619-624

• Nursing Care:• NVS as ordered• Administer Nimodipine as orders (60mg Q4h or 30mg

Q2H)• Monitor carefully for neurological deficits• Monitor BP closely (may cause hypotension)


⑥ TMPERATURE CONTROL:• Neurogenic Hyperthermia is

common in SAH (41-71%) Neurosurgery 2010; 66:696-700

• Normothermia improved outcomes.

• Nursing Care:• Temperature Q4H & PRN• Cooling as ordered• Tylenol as ordered


⑦ SEIZURE MANAGEMENT:• During hospitalization, 5% of

SAH patients, will have seizures. • Anticonvulsant therapy may be

indicted in these patients.• Nursing Care:

• NVS• Monitor for seizure activity• Administer anticonvulsants and

benzodiazepines as ordered.


⑧ ICP MANAGEMENT:

• Elevated ICP will result in a poor neurological outcome.

• Draining CSF can lower ICP.• Nursing Care:

• NVS as ordered• Q1H + PRN ICP & CPP• Sedation• HOB 30 degrees• PaCo2 between 35-45 mmHg

Subarachnoid Hemorrhage⑨ PAIN / NAUSEA CONTROL:• Severe headaches are common in

SAH.• Pain control is essential for patient

comfort.• Excessive pain may cause

unwanted hypertension.• Nausea and emesis is common

with SAH patients• Administer antiemetic

medications, as ordered, to prevent vomiting.

• Vomiting increases the risk of rebleeding, and increases ICP.

Subarachnoid HemorrhageLET’S REVIEW:

• Rebleeding is an early and catastrophic complication of SAH.

• Early aneurysm repair reduces the risk of rebleeding.

• EVD are inserted to drain excessive CSF and to monitor ICP.

• Nimodipine Therapy is used to mitigate vasospasm, and to prevent cerebral ischemia.

• Once the aneurysm is secured Hypertensive Therapy is used to prevent cerebral ischemia.

• Careful neurological assessment is essential.


Thank you….

References:

https://www.youtube.com/watch?v=WNcGiM5kH5s

Stroke 1994; 25(7) 1342

Stroke 2009; 40(3) 994

Stroke 2012; 43:1711-37

NEJM 1983; 308:619-624




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Subarachnoid hemorrhage