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Ectopic pregnancy A Project PowerPoint Presentation

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Slide 1 - Subarachnoid Haemmorhage By Fiona Hill HMO3 Surgical
Slide 2 - Introduction 20% of strokes are hemorrhagic: - half SAH - half ICH Average case fatality rate for SAH: 51% Of these, approx: 10% of patients die prior to reaching the hospital 25% die within 24 hours 45% die within 30 days More than one third of survivors have major neurologic deficits
Slide 3 - Anatomy
Slide 4 - SAH: Overview Subarachnoid hemorrhage implies blood within the subarachnoid space from some pathologic process. Most SAHs are caused by ruptured saccular aneurysms ~ 77% Dilatations of a vascular lumen caused by wall weakness Commonly in the Circle of Willis Other causes include: trauma, AVM, vasculitides, intracranial arterial dissections, amyloid angiopathy, and illicit drug use. 1-5 percent of people have aneurysms. Of these 20 -30 % have multiple Aneurysmal SAH occurs at an estimated rate of 3 to 25 per 100,000 population. Mean age at onset: 55 years (40 and 60 years of age)
Slide 5 - History Sudden onset of a severe headache. Prodromal headache from minor blood leakage (sentinel headache) is reported in 30-50% of aneurysmal SAH. Symptoms of meningeal irritation - 75% of cases. Nausea and/or vomiting. Photophobia and visual changes. > 25% of patients experience seizures close to onset. Loss of consciousness: 50% of patients at time of bleed.
Slide 6 - Physical Examination Vital signs 50% have mild-to-moderate blood pressure (BP) elevation. Global or focal neurologic abnormalities in more than 25% of patients Syndromes of cranial nerve compression Motor deficits from middle cerebral artery aneurysms in 15% of patients Seizures Ophthalmologic signs: eg Papilledema, haemorrhages
Slide 7 - Location of aneurysms 85% of saccular aneurysms occur in the anterior circulation. Most common sites of rupture : Internal carotid artery, including the posterior communicating junction (41%) The anterior communicating artery/anterior cerebral artery (34%) The middle cerebral artery (20%) The vertebral-basilar arteries (4%) Other arteries (1%)
Slide 8 - Risk Factors Cigarette smoking  Hypertension Excessive Alcohol Consumption Genetic risk  Sympathomimetic drugs x
Slide 9 - Grading scales Hunt and Hess grading system Grade 1 - Asymptomatic or mild headache Grade 2 - Moderate-to-severe headache, nuchal rigidity, and no minimal neurological deficit. Grade 3 - Mild alteration in mental status (confusion, lethargy), mild focal neurological deficit Grade 4 - Stupor and/or hemiparesis Grade 5 - Comatose and/or decerebrate rigidity WFNS scale Grade 1 - Glasgow Coma Score (GCS) of 15, motor deficit absent Grade 2 - GCS of 13-14, motor deficit absent Grade 3 - GCS of 13-14, motor deficit present Grade 4 - GCS of 7-12, motor deficit absent or present Grade 5 - GCS of 3-6, motor deficit absent or present Fischer scale (CT scan appearance) Group 1 - No blood detected Group 2 - Diffuse deposition of subarachnoid blood, no clots, and no layers of blood greater 1 mm Group 3 - Localized clots and/or vertical layers of blood 1 mm or greater in thickness Group 4 - Diffuse or no subarachnoid blood, but intracerebral or intraventricular clots are present
Slide 10 - Imaging First line: CT scan without contrast Sensitivity decreases with time from onset and with older resolution scanners. Cerebral angiography is performed once the subarachnoid hemorrhage diagnosis is made. This study assesses the following: vascular anatomy, current bleeding site, and presence of other aneurysms. This study helps plan operative options. Angiography findings are negative in 10-20% of patients with subarachnoid hemorrhage. MRI/MRA is performed if no lesion is found on angiography.
Slide 11 - Lumbar puncture Indicated if the patient has possible subarachnoid haemorrhage and negative CT scan findings. Perform CT scan prior to LP to exclude any significant intracranial mass effect or obvious intracranial bleed. Timing: LP may be negative less than 2 hours after the bleed; LP is most sensitive at 12 hours after symptom onset. Findings: RBC remain consistently elevated in 2 sequential tubes. Xanthochromia usually is seen by 12 hours after the onset of bleeding, LP findings were thought to be positive in 5-15% of all subarachnoid hemorrhage presentations that are not evident on the CT scan.
Slide 12 - Case: Mrs Agnes A 51 y/o Lebanese lady comes in with her husband complaining of a vague headache lasting two days which this morning acutely progressed into a severe occipital headache.
Slide 13 - Case: Mrs Agnes PCx: Has had a vague 2/10 headache for 48/24. Acutely developed severe headache this am. 10/10 Associated symptoms of photophobia, neck pain, nausea. PMHx: TIIDM – insulin dependant Hypertension Hypercholesterolaemia GORD Meds: Insulin, frusemide, OCP, lansoprazole NKDA Social Hx: Housewife, lives with husband + two children. Current smoker, 30+ pack years. Alcohol: nil Other substances: nil
Slide 14 - Case: Mrs Agnes Examination: Pt drowsy, photophobic to lights in room. GCS: 14/15 E3V5M6 Vitals: - TEMP 36.5 - BP 200/90mmHg - PR 94bpm - RR 15 Sat 100% 2L. Neuro: PEARL, FROEM, CN II-XII – unremarkable. UL + LL – normal tone, power 5/5, reflexes normal, sensate throughout. CVS, Resp, Abdo examination unremarkable.
Slide 15 - First Line Investigations Bloods: FBC, U&E, Coags, Troponin, G&H Imaging: CTA
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Slide 19 - Case: Diagnosis Acomm aneurysm WFNS Grade II Fisher III SAH secondary to Acomm A
Slide 20 - Case: Mrs Agnes Over next 1/24 - progressively more drowsy What are you concerned about? Raised intracranial pressure What would you do about it? EVD inserted What’s the next step? Angiogram +/- coiling
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Slide 23 - Case: Management Whats next? Emergengy theatre when available to clip aneurysm. Interim: IV nimodipine + PRN hydralazine Load Phenytoin SBP strickly <140mmHG for unsecured aneurysm. QIH neuro obs, Head up at 30-45 degress. FFMN CVC Notify if GCS drops >2, unreactive pupils or 2mm or more in difference
Slide 24 - Case: Mrs Agnes
Slide 25 - Thank you!
 

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