EDWIN TORRES HUAMANI MR NEUROCIRUGIA HOSPITAL ALBERTO SABOGAL SOLOGUREN

La incidencia anual de la hemorragia subaracnoidea es de aproximadamente 10/100.000. Prevalencia anual 25 000 a 30 000 anual Es una patologa que tiene una alta morbi-mortalidad. Se incrementa con la edad promedio 40 a 60 aos. 1,6 mas en mujeres q varones. Americanos negros mayores riesgo.

 Aneurismas idiopticos (70 90%)

Causa desconocida (10%) Malformaciones AV

Extensin de una HIC

Drogas simpaticomimticas Hemorragia intratumoral

Ruptura de aneurismas micticos

Disecciones Alteraciones de la coagulacin

 HTA

Consumo de alcohol.
Consumo de cigarrillos. Cocana .

Drogas simpaticomimticos.
Influencia climtica. Sndromes susceptibles de aneurismas.

Sndrome aneurisma intracraneal familiar.

 Treatment of high blood pressure with

antihypertensive medication is recommended to prevent ischemic stroke, intracerebral hemorrhage, and cardiac, renal, and other end-organ injury (Class I; Level of Evidence A). Hypertension should be treated, and such treatment may reduce the risk of aSAH (Class I; Level of Evidence B). Tobacco use and alcohol misuse should be avoided to reduce the risk of aSAH (Class I; Level of Evidence B).

 Cerebrovascular imaging is generally recommended to

identify remnants or recurrence of the aneurysm that may require treatment (Class I; Level of Evidence B). Consumption of a diet rich in vegetables may lower the risk of aSAH (Class IIb; Level of Evidence B).

 Alta mortalidad.

Factor paciente, factor aneurisma, factor institucin.

Re sangrado mortalidad 70%, es mximo en el primer

da de sangrado. Luego la frecuencia es constante 1 a 2% sobre las siguientes 4 semanas. Resangrado es 3% por ao. Ultraearly rebleeding.

 1. The initial clinical severity of aSAH should be

determined rapidly by use of simple validated scales (eg, Hunt and Hess, World Federation of Neurological Surgeons), because it is the most useful indicator of outcome after aSAH (Class I; Level of Evidence B). 2. The risk of early aneurysm rebleeding is high, and rebleeding is associated with very poor outcomes. Therefore, urgent evaluation and treatment of patients with suspected aSAH is recommended (Class I; Level of Evidence B). 3. After discharge, it is reasonable to refer patients with aSAH for a comprehensive evaluation, including cognitive, behavioral, and psychosocial assessments (Class IIa; Level of Evidence B). (Newrecommendation)

 Cefalea: 74 - 80% Nuseas y vmitos: 70 80%

Alteracin del nivel de conciencia: 60 70%

Prdida transitoria de la conciencia: 50% Rigidez de nuca: 40 - 50%

Alteraciones cardio - respiratorias

 Sangrado inicial Resangrado

Vasoespasmo
Hidrocefalia Alteraciones hidro-electrolticas

Alteraciones cardio - respitorias

 Grado I: Asintomtico, cefalea leve Grado II: Cefalea severa, rigidez de nuca, paresia de

pares craneales Grado III: Obnubilacin, confusin, dficit motor leve Grado IV: Estupor, paresias moderadas o severas Grado V: Coma, rigidez de descerebracin

 Grado I: GCS 15/15

Grado II: GCS 13-14/15 sin dficit motor Grado III: GCS 13-14/15 con dficit motor

Grado IV: GCS 7 12

Grado V: GCS 3 - 6

 Grado I: No se visualiza sangre en la TAC Grado II: Sangre en una capa fina < 1 mm de capa

vertical Grado III: Cogulos localizados, capa gruesa = > 1 mm de capa vertical Grado IV: Sangre intracerebral o intraventricular sin capa gruesa en el espacio subaracnoideo

RECOMENDACIONES
1. aSAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for aSAH should exist in patients with acute onset of severe headache (Class I; Level of Evidence B). 2. Acute diagnostic workup should include noncontrast head CT, which, if nondiagnostic, should be followed by lumbar puncture (Class I; Level of Evidence B). 3. CTA may be considered in the Workup of aSAH. If an aneurysm is detected by CTA, this study may help guide the decision for type of aneurysm repair, but if CTA is inconclusive, DSA is still ecommended (except possibly in the instance of classic perimesencephalicaSAH) (Class IIb; Level of Evidence C).

RECOMENDACIONES
4. Magnetic resonance imaging may be reasonable for the diagnosis of aSAH in patients with a nondiagnostic CT scan, although a negative result Connolly et al Management of neurysmal Subarachnoid Hemorrhage does not obviate the need for cerebrospinal fluid analysis (Class IIb; Level of Evidence ). 5. DSA with 3-dimensional rotational angiography is indicated for detection of aneurysm in patients with aSAH and for planning (Class I; Level of Evidence B).

 Resangrado Vasoespasmo Hidrocefalia

Edema cerebral
HEC Convulsiones

 1. Between the time of aSAH symptom onset and aneurysm

obliteration, blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertensionrelated rebleeding, and maintenance of cerebral perfusion pressure (Class I; Level of Evidence B). (New recommendation) 2. The magnitude of blood pressure control to reduce the risk of rebleeding has not been established, but a decrease in systolic blood pressure to <160 mm Hg is reasonable (Class IIa; Level of Evidence C). 3. For patients with an unavoidable delay in obliteration of aneurysm, a significant risk of rebleeding, and no compelling medical contraindications, shortterm (<72 hours) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce the risk of early aneurysm rebleeding (Class IIa; Level of EvidenceB).

 Espesor del cogulo subaracnoideo Sangre en los ventrculos laterales Velocidades > 110 cm/seg en el da 5 GCS < 14 Ruptura de aneurismas de la ACI ACA

 Especies reactivas del oxgeno Productos de la peroxidacin lipdica Eicosanoides Bilirrubina Endotelinas Dficit de xido ntrico

 Clnica Doppler transcraneano

Estudios de FSC
Arteriografa Descartar otras complicaciones

 Oral nimodipine should be administered to all

patients with Asah (Class I; Level of Evidence A). Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (Class I; Level of Evidence B). Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Class Iia; Level of Evidence B). Perfusion imaging with CT or magnetic resonance can be useful to identify regions of potential brain ischemia (Class IIa; Level of Evidence B).

 Induction of hypertension is recommended for

patients with DCI unless blood pressure is levated at baseline or cardiac status precludes it (Class I; Level of Evidence B).

 Frecuencia: 8 - 34% Hidrocefalia comunicante

Hidrocefalia obstructiva
Diagnstico mediante la TAC

1. aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage, depending on the clinical scenario) (Class I; Level of Evidence B).
2. aSAH-associated chronic symptomatic hydrocephalus should be treated with permanent cerebrospinal fluid diversion (Class I; Level of Evidence C). 3. Weaning EVD over >24 hours does not appear to be effective in reducing the need for ventricular shunting (Class III; Level of Evidence B).

4. Routine fenestration of the lamina terminalis is not useful for reducing the rate of shunt-dependent hydrocephalus and therefore should not be routinely performed. (Class III; Level of Evidence B).

1 The use of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period (Class IIb; Level of Evidence B). 2. The routine long-term use of anticonvulsants is not recommended (Class III; Level of Evidence B) but may be considered for patients with known risk factors for delayed seizure disorder, such as prior seizure, intracerebral hematoma, intractable hypertension, infarction, or aneurysm at the middle cerebral artery (Class IIb; Level of Evidence B).

 Cardiovasculares
Respiratorias Metablicas

Hematolgicas
Gastrointestinales Infecciosas

Renales

En un estudio que incluy a 242 pacientes, se demostr una asociasin entre el score de Hunt y Hess y el desarrollo de disfunciones extracerebrales. El 81% de los pacientes desarrollaron al menos 1 disfuncin extracerebral. 41,8% fallecen debido a FMO

Gruber A et al Crit Care Med 2009; 27:50514

 Estabilizacin inicial Medidas generales de tratamiento

Tratamiento de la causa de la HSA

Tratamiento de las complicaciones

 Evaluar va area y signos vitales Correccin de hipotensin e hipoxia Realizacin de una TAC de encfalo y/o puncin

lumbar Solicitar una angiografa Internar en UTI, intermedia o unidad de stroke

 Reposo Plan amplio de hidratacin Analgesia

Bloqueantes clcicos
Profilaxis de las convulsiones Profilaxis de la TVP TEP

Control de la presin arterial

 Va area permeable Adecuada ventilacin y oxigenacin Mantener estabilidad cardio-circulatoria TAC de urgencia Monitoreo neurolgico Manejo de hipertensin endocraneana

 Mantener adecuada ventilacin y oxigenacin

Control de la tensin arterial y arritmias

Plan amplio de hidratacin Evitar hiponatremia e hiperglucemia

Bloqueantes clcicos
Profilaxis de las convulsiones Soporte nutricional Prevencin de la HDA, TVP y TEP

H y H I y II: 75 90% de buena recuperacin 5 15% de estado veg. y muerte H y H III: 55 75% de buena recuperacin 15 30% de estado veg. y muerte 30 50% buena recuperacin 35 45% de estado veg. y muerte 5 15% de buena recuperacin 75 90% de estado veg. y muerte

H y H IV:

H y H V:

 1. Administration of large volumes of hypotonic fluids and

intravascular volume contraction is not recommended after aSAH (Class III; Level of Evidence B). 2. Monitoring volume status in certain patients with recent aSAH by some combination of central venous pressure, pulmonary wedge pressure, and fluid balanceis reasonable, as is treatment of volume contraction with crystalloid or colloid fluids (Class Iia; Level of Evidence B). 3. Aggressive control of fever to a target of normothermia by use of standard or advanced temperature modulating systems is reasonable in the acute phase of aSAH (Class IIa; Level of Evidence B). 4. Careful glucose management with strict avoidance of hypoglycemia may be considered as part of the general critical care management of patients with aSAH (Class IIb; Level of Evidence B).

 5 The use of packed red blood cell transfusion to treat anemia

might be reasonable in patients with aSAH who are at risk of cerebral ischemia. The optimal hemoglobin goal is still to be determined (Class Iib; Level of Evidence B).

6. The use of fludrocortisone acetate and hypertonic saline

solution is reasonable for preventing and correcting hyponatremia (Class IIa; Level of Evidence B).

7. Heparin-induced thrombocytopenia and deep venous

thrombosis are relatively frequent complications after aSAH. Early identification and targeted treatment are recommended, but further research is needed to identify the ideal screening paradigms (Class I; Level of Evidence B).