Copy - IPH & SAH

Rch UNIVERSITY neuroscience

Case Presentation

Student: Alessandra Lisa Loreto

March 30, 2023

index

PLAN OF CARE

INTRODUCTION

CASE PRESENTATION

VITAL SIGNS

HISTORY & PHYSICAL

MEDICATIONS

IMAGING

FINDINGS

OUTCOME

IPH & SAH

REFERENCES

INTERVENTION

Case Study

• 78 years old female
• Complaints of right eye pain
• Right-sided weakness
• Slurring
• Right-sided facial droop

Events precipitating incident

Presentations

Course of Action- BEFAST

STROKE CHAIN OF SURVIVAL

1. GCS: 12
1. Eyes: 4-reactive, R>l, crosses midline
2. Voice: 3-slurrs
3. motor: 5-localizes
2. NIH: 12
1. AMS, alert to voice
1. cannot follow commands/answer questions correctly
2. unintelligible speech
3. Right droop
4. moves bue, drift on ble
3. ABC'S
4. Vitals:
1. Blood PRessure: 158/93
2. Heart Rate: 102
3. Sp02: 96% on ra
4. Respirations: 16
5. temp: 98.2
5. Labs:
1. Blood sugar: 116
2. K: 3.3 l
6. chest xr: unremarkable

Head CT

CTA

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"As blood extravasates from the ruptured artery, neurologic deficit arises as adjacent brain tissue is disrupted, displaced, and compressed"

Causes of IPH

• Aneurysms
• AVMs
• dAVF
• Dissections
• HTN
• Cavernomas
• Beta amyloids

• Epidural Bleed:This bleed happens between the skull bone and the outermost membrane layer; the dura mater.
• Subdural Bleed: This bleed happens between the duramater and the arachnoid membrane.
• Subarachnoid Bleed: This bleed happens between the arachnoid membrane and the pia mater.

IPH/sah

intraparenchymal hemorhage

1. Ruptured left frontal AVM nidal aneurysm.
2. Technically successful coil embolization of the ruptured left frontal AVM nidal aneurysm.
3. Unruptured residual AVM drains to the left cavernous sinus; recommend conservative management for now.
4. Unruptured Right MCA aneurysm

Interventions

Ruptured Left frontal AVM aneurysm

S/P coilbolization of nidal aneury

1. 1:1 MICU MANAGEMENT
2. FLAT FOR AT LEAST 2 HOURS
3. NEUROCHECKS AND NEUROVASCULAR CHECKS
4. ST EVAL
5. MONITORING FOR SIGNS/SYMPTOMS OF BLEEDING
6. EDUCATION FOR PT/FAMILY
7. REDUCE/ALLEVIATE SYMPTOMS
8. BEDREST & REDUCED STIMULI

Postop aftercare

1. GCS: 12
1. Eyes: 4-reactive, left gaze
2. Voice: 2-moans
3. motor: 6-obeys
2. NIH: 18
1. AMS, alert to voice
1. intermittently follows
2. moans
3. Right droop
4. moves lue/ble but drifts, rue flexed
3. ABC'S
4. Vitals:
1. Blood PRessure-on nicardipine drip
2. Heart Rate: sr-st
3. Sp02: 2l nc
4. Respirations: 16
5. temp: afebrile
5. Labs:
1. Blood sugar: normal
2. hypokalemic
6. chest xr: unremarkable

Plan

Outcome

CONSERVATIVE MANAGEMENT

*Increased IPH with increased effacement of Left lateral horn

Admit to ICU with post ruptured AVM nidal aneurysm embolization

BLOOD PRESSURE CONTROL

• Normotensive for now x 24 hours, then OK for permissive HTN if vasospams

• Post embolization CT Head

• IPH measures 6 cm AP x 4.4 cm transverse
• Left Sylvian fissure SAH similar to initial head CT
• No midline shift
• Suspicion of rebleeding, requiring serial CTH
• Concerns for emergent evacuation
• Concerns for AVM resection

Daily TCD's

Nimodipine 60mg q4h; ok to hold single dose if SBP < 100

Normal Saline to maintain isovolemia Hold Cilostazol for now OK to extubate from NIR perspective when meets extubation criteria

medical intensive care

Medical Management

Hourly Neurochecks

Surveillance

Isovolemia

PreventativeSeizures Vasospasms Bleeding at site Clotting Bowel regimen Daily labs

NIHSS

Maintenance IVF

Follow-up

Increased ICPRebleedingNew or worsening focal deficits Hydrocephalus Seizures Emergent hemicraniectomy

Prevents vasospasmsSTRICT avoidance of drop in blood volume Helps to increase volume/puts more pressure into vessels

CT scansDaily TCD's Daily weights

plan of care

05

01

Respiratory

Cardiovascular

Labs

Genitourinary

Gastrointestinal

• Telemetry
• SBP <60
• Nicardipine drip prn
• Prn Labetalol and hydralazine
• MAP > 65

• Strict Euvolemia
• Replace with NS
• I&O's
• Avoid hypotonic Solutions

• Spo2 > 92%
• Vent management
• Daily SBT
• PA02 > 80
• Normal C02
• Monitor Cxr & ABG

• Daily CBC, BMP
• Serum Sodiums q6h
• Goal:
• Replete electrolytes

• Tube Feeds to goal
• ST eval
• Bowel Regimen
• PPI
• Monitor Glucose (140-180)
• Hold SSI if < 180

• Nexium/Protonix
• Bactroban
• Potassium Chloride

• Magnesium Sulfate

• Tylenol
• Hydralazine
• Labetalol
• Norepinephrine

imaging

follow-up head ct

• Stable minimal midline shift Lt to Rt 2-3 mm
• Stable IPH in Left frontal lobe
• Stable SAH

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daily tcd's

Looks at the speed and velocity of blood vessel

• Normal Velocity:
• MCA <20
• ACA < 90
• Lindegaard ratio: Velocity of ICA/ECA

"Without evidence of vasospasm"

complications

• ALOC
• Inability to protect airway
• Intubation
• Pneumothorax

development

HUNT HESS SCALE FOR SAH

Spetzler-Martin 4

The Spetzler Martin Grading Scale estimates the risk of open neurosurgery for a patient with AVM, by evaluating AVM size, pattern of venous drainage, and eloquence of brain location.

Grade 1 AVM would be considered as small, superficial, and located in non-eloquent brain, and low risk for surgery. Grade 4 or 5 AVM are large, deep, and adjacent to eloquent brain. Grade 6 AVM is considered not operable.

• SIZE 2
• ELOQUENT CORTEX
• DEEP VEIN

CONSERVATIVE MANAGEMENT VS. SURGICAL INTERVENTION

ACCORDING TO THE ARUBA TRIAL..*LOWER INCIDENCE OF STROKE OR DEATH IN THE GROUP RECEIVING CONSERVATIVE MANAGEMENT * DID NOT SPECIFY A TREATMENT STRATEGY *EXCESS VARIANCE WITH SMALL NUMBER OF PATIENTS ENROLLED AND SHORT-TERM FOLLOW-UP

ARUBA TRIAL A RANDOMIZED TRIAL OF UNRUPTURED BRAIN ARTERIOMALFORMATIONS

Any attempt to study endovascular AVM therapy will benefit from the regimentation of pretreatment decision making and treatment techniques.

ENDOVASCULAR EMBOLIZATION IS THE COMMON PRACTICE FOR RUPTURED AVMS

PREOPERATIVE EMBOLIZATION FOR NEUROSURGERY OR RADIATION THERAPY

The current levels of evidence for any of the aspects of AVM treatment are low.

Stand-alone embolization versus preoperative embolization and surgical resection has not yet been studied in a prospective, randomized paradigm with a well-defined patient cohort and regimented techniques

Bibliography

Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association

19 Apr 2018https://doi.org/10.1161/CIR.0000000000000567Circulation. 2018;137:e661–e689

Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

22 Jun 2017https://doi.org/10.1161/STR.0000000000000134Stroke. 2017;48:e200–e224

INTRODUCTION TO CRITICAL CARE NURSING 7TH EDITION

ASOLE, KLEIN, MOSELEY, 2017

STROKE

P.B. Gorelick, ... A.K. Pajeau, in Encyclopedia of Gerontology (Second Edition), 2007

Bibliography

"You must be APHASIA, because you left me speechless"

Thank you

Any questions?