Ebook The practice of emergency and critical care neurology: Part 2

(BQ) Part 2 book The practice of emergency and critical care neurology has contents: Management of specific disorders in critical care neurology, management of systemic complications, postoperative neurosurgical and neurointerventional complications, formulas and scales,... and other contents.

Management of Specific Disorders in Critical Care Neurology

Aneurysmal Subarachnoid Hemorrhage

Major medical institutions may admit 50– 75

patients with an aneurysmal subarachnoid hemorrhage (SAH) a year A  multidisciplinary

team is required to respond to the immediate

needs of the patient and to plan for repair of the

aneurysm.8,42,101,154,175 Expertise may prevent poor

outcome.25,47,133

After aneurysmal rupture, 10% of patients die suddenly or within the first hours before ever

receiving adequate medical attention Many of

these patients had marked intraventricular

exten-sion of the hemorrhage and acute pulmonary

edema, both reasons for sudden death.144 Of those

most severely affected who reach the emergency

department (ED) or neurosciences intensive care

unit (NICU), half die within 3 months Some of

these patients may have been found pulseless and

required prolonged cardiopulmonary

resuscita-tion Patients who survive a major first rupture

face the immediate risk of catastrophic

rebleed-ing, rapidly developing hydrocephalus, potentially

life- threatening pulmonary edema, and cardiac

arrhythmias Presentation in a poor clinical

condi-tion often indicates that the hemorrhage is not

con-fined to the subarachnoid space but rather there is

intraventricular and intraparenchymal extension

Many have additional large ventricles and are in

need of CSF diversion with a ventriculostomy

The critical steps in managing SAH are to surgically clip the aneurysm or occlude the sac

by inserting platinum coils, to treat clinical

neu-rologic deterioration early, and to manage major

systemic complications.169

Aneurysmal subarachnoid hemorrhage is a prime example of a neurocritical and neurosurgi-

cal disorder where outcome in the first days after

presentation cannot be judged adequately and

care of the initially comatose patient can lead to a

satisfactory outcome

Fortunately, a considerable proportion of patients with SAH present with severe head-

ache and are alert with little other findings Early

repair of the aneurysm may result in an excellent

outcome

C L I N I C A L R E C O G N I T I O N

The incidence of aneurysmal SAH varies, but overall is 10 cases per 100,000 persons per year (doubled in Finland and Japan).112 The risk is nearly two times higher in women (particularly with smoking history) than in men and in blacks than in whites Subarachnoid hemorrhage is more common in patients with a family history of SAH,101 polycystic kidney disease, systemic lupus erythematosus, or Ehlers- Danlos disease (Capsule 26.1).60,61

Aneurysmal SAH may be manifested in many ways Typically, an unexpected instantaneous headache warns the patient of a very serious dis-order and is often described as excruciating and overwhelming113 (Chapter 4)

Vomiting may occur several minutes into the ictus as a result of further distribution of blood throughout the subarachnoid space Profuse vom-iting may override the headache and has been mistaken for a “gastric flu” by the patient or ini-tially consulted physician

With an incomplete medical history and no inquiry about acute headache, patients may be wrongly transferred to a medical ICU (cardiac resuscitation and pulmonary edema), gastroin-testinal service (vomiting), or coronary care unit (cardiac arrhythmias with new electrocardio-graphic [EKG] changes) Other unusual clini-cal presentations have included acute paraplegia (anterior cerebral artery aneurysm rupture into frontal lobes) and severe thoracic and lumbar pain caused by meningeal irritation These pre-sentations may have resulted in a delay in cranial computed tomography (CT) scan imaging.The abruptness of the headache is not specific for SAH; it may occur in conditions such as arte-rial dissection, pituitary apoplexy, hypertensive encephalopathy, spontaneous intracranial hypo-tension, and cerebral venous thrombosis43,44,143

(Chapter 4) Some patients briefly lose ness Inappropriate behavior and agitation or drowsiness may follow Localizing neurologic findings, although transient, may indicate the

conscious-Part VII: Management of Specific Disorders

318

site of the ruptured aneurysm For example,

patients with a ruptured middle cerebral artery

(MCA) aneurysm may have transient or

persis-tent aphasia In patients with a ruptured MCA

aneurysm and intraparenchymal extension, paresis often is found Abulia most often occurs

hemi-as a complication of a rupture of an aneurysm of the anterior cerebral artery (ACA) Generalized

What causes aneurysms to rupture is puzzling Risk factors have included recently documented enlargement (rupture of aneurysms < 4 mm is uncommon; most ruptured aneurysms are 7– 8

mm, and risk of rupture increases significantly in aneurysms of ≥ 10 mm), 88 hypertension, rette smoking, and family history of aneurysms and SAH Aneurysmal rupture has been reported

ciga-to have occurred during weightlifting, sexual orgasm, and brawling, events that suggest acute hypertensive stress on a thin aneurysmal wall 160 However, at least 50% of patients have SAH while at rest Seasonal changes have been implicated with increased rupture rate during colder temperatures and influenza peaks An association between a recent infection and aneurysmal rupture has not been definitively established, but is plausible

Intracranial pressure rises dramatically to at least the level of the diastolic blood pressure, causing cerebral perfusion standstill The increase in intracranial pressure decreases within 15 minutes but may persist if acute hydrocephalus or a shift from intracerebral hematoma has occurred Rupture stops within 3– 6 minutes after ejection of up to 15– 20 mL/ min into the basal cistern.

Hemodynamic variables have been tested on cadaver and computer models Variables that may determine rupture are wall shear stress, intra- aneurysmal flow velocity, and inflow jet and angles of entry and vortexes Wall sheet stress is caused by the frictional force of blood, and areas with high forces may fragment the internal elastic lamina and cause blebs and aneurysms 56,148

Hemodynamic stress may cause morphologic changes involving the endothelial lining of the walls, with intimal hyperplasia, and organizing thrombosis Many ruptured vacular aneurysms show inflammatory changes, with infiltrating leukocytes and macrophages promoting fibrosis Other theories focus on the multitudes of vortices or unstable flow High inflow jets with large impact zones may result in thrombus or daughter sac formation 20,21

VORTEX FORMATION

DAUGHTER SAC

Subarachnoid hemorrhage Left: aneurysmal rupture causing diffuse subarachnoid hemorrhage

Right: Vortex formation in aneurysm.

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 319

tonic- clonic seizures are not quite so often seen at

the time of rupture, and it is possible that extensor

posturing or brief myoclonic jerks with syncope at

onset may be mistaken for a seizure These

clini-cal features in SAH are identiclini-cal whether or not

an aneurysm is detected Different presentation is

expected, however, in an established benign

vari-ant of nonaneurysmal SAH, so- called

pretrun-cal or perimesencephalic SAH The patients are

almost exclusively alert Loss of consciousness is

seldom observed and seizures are absent, and the

onset of headache is less acute— in minutes rather

than a second

Neurologic examination reveals neck stiffness

in most patients, except those seen early after the

initial event and those who are comatose Nuchal

rigidity can be demonstrated by failure to flex the

neck in the neutral position and failure of the neck

to retroflex when both shoulders are lifted Retinal

subhyaloid hemorrhages are present in

approxi-mately 25% of the patients (Figure 26.1) (This

syndrome is more often observed in comatose

patients and after rebleeding.) These flat- topped

hemorrhages occur when outflow in the optic

nerve venous system is suddenly obstructed by the

intracranial pressure (ICP) wave.55 Visual loss may

be severe, with perception of light or hand motion

only, if the hemorrhage expands and ruptures

into the vitreous (Terson syndrome).131 Cranial

nerve abnormalities occur infrequently in SAH

unless a giant basilar artery aneurysm (third- or

sixth- nerve palsy) or a large carotid artery rysm (chiasmal syndromes) directly compresses surrounding structures The pupil is dilated and unreactive to light in a third- nerve palsy because

aneu-of compression aneu-of the exteriorly located fibers that form the light reflex However, up to 15% of poste-rior communicating artery aneurysms may occur with a pupil- sparing third- nerve palsy Aneurysm

of the basilar artery may produce unilateral or bilateral third- or sixth- nerve palsy.87 If the basilar artery aneurysm enlarges and progressively com-presses the oculomotor nuclei of the pons, hori-zontal gaze paralysis, skew deviation, internuclear ophthalmoplegia, and nystagmus occur, com-monly in association with long- tract signs such

as hemiparesis and ataxia Occlusion of the mal posterior cerebral artery, often encased in a giant aneurysm, may occur, causing either classic Weber syndrome (Chapter 30) due to mesenceph-alon infarction (third- nerve palsy with opposite hemiparesis) or homonymous hemianopia due to occipital lobe infarction

proxi-In comatose patients, a certain eye position may be localizing These forced gaze positions include downward gaze and wall- eyed bilateral internuclear ophthalmoplegia, and are char-acteristically seen with acute hydrocephalus (Figure 26.2).90

Hemiparesis that usually involves the face, arm, and leg should point to an intracranial hema-toma in SAH An anteriorly placed intracranial

FIGURE  26.1: Subhyaloid and vitreous hemorrhages Top:  Subhyaloid hemorrhage in subarachnoid rhage Bottom left: Red reflex is absent from vitreous hemorrhage also known as Terson syndrome Bottom mid- dle: Improvement in vision Bottom right: Normal red reflex as shown by retro illumination with fundus camera.

hemor-Part VII: Management of Specific Disorders

320

hematoma in the frontal lobe may not produce

motor weakness but may be associated with

agita-tion and bizarre behavior Many patients are

con-fused, and may ramble nonsensically Korsakoff

syndrome with impaired recall and fabrications

may occur in ruptured anterior communicating

aneurysm Abulia, a general sense of disinterest,

and lackluster attention are also features,

becom-ing apparent days later.62 Temporal lobe

hema-toma in the dominant hemisphere may produce

aphasia, but often associated mass effect and

brainstem displacement decrease the level of

con-sciousness and word output

Generalized tonic- clonic seizures are

accom-panied by aneurysmal rupture in 10% of patients,

or these appear during rebleeding These

“sei-zures” are likely ischemic in nature and a result

of a major increase in ICP Nonconvulsive status

epilepticus may occur, and the clinical signs are

difficult to differentiate from the effects of initial

rupture However, in our experience,

electro-encephalography (EEG) has rarely documented

nonconvulsive status epilepticus Epilepsia

par-tialis continua is equally uncommon in

aneurys-mal SAH It is more common in patients with

additional subdural hematoma and when delayed

cerebral infarction occurs

Systemic manifestations may include

respira-tory failure and oxygen desaturation from

aspi-ration, pulmonary edema, or obstruction of the

airway Cardiac arrhythmias may involve the

entire spectrum of supraventricular and

ventricu-lar arrhythmias Most of the time they are

asso-ciated with EKG changes, which may simulate

or indicate acute myocardial infarction Elevated

troponin I levels may occur in approximately 25%

of the cases seen on the first day Major cardiac

arrhythmias may lead to cardiac resuscitation

after SAH and generally portend poor outcome, but patients may improve substantially.152

When patients are comatose at presentation, it

is largely due to the initial rise in ICP with tion of cerebral blood flow and, as a consequence, diffuse bihemispheric ischemia.79 However, one should try to make a distinction between the direct effects of the initial impact and early neurologic deterioration due to other causes Acute hydro-cephalus may have developed in the interim, and placement of a ventricular drain could markedly improve the level of consciousness Patients admit-ted days after the ictus may have symptomatic cerebral vasospasm, and focal signs and symptoms may not be present Coma may be caused by brain tissue shift from a large expanding hematoma in the sylvian fissure Removal of the hematoma and repair of the aneurysm may result in marked improvement

reduc-The clinical course in poor- grade aneurysmal SAH is unpredictable in the first 24– 48 hours Patients moribund at presentation may improve

in a matter of hours without much neurosurgical

or medical intervention, although the prognosis may remain guarded

Systemic metabolic factors may ute, and each of them should be excluded Measurements of arterial blood gas, electrolytes, and serum glucose must be obtained rapidly in every patient with SAH who enters the NICU

contrib-A simple clinical grading system proposed by the World Federation of Neurological Surgeons (WFNS) introduced the Glasgow Coma Scale in SAH grading46,139 (Table 26.1), and for practical reasons the severity is graded as good (WFNS I– III) or poor (WFNS IV or V) A  correlation between outcome and initial grading level exists This rather crude scale may also guide the timing

FIGURE  26.2: Wall- eyed bilateral internuclear

oph-thalmoplegia with acute hydrocephalus in patient with

aneurysmal subarachnoid hemorrhage.

TABLE 26.1. GRADING SYSTEM PROPOSED BY THE WORLD FEDERATION

OF NEUROLOGICAL SURGEONS FOR THE CLASSIFICATION OF SUBARACHNOID

HEMORRHAGE

Scale Score Motor Deficit

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 321

of surgery Some neurosurgeons defer craniotomy

for aneurysmal clipping in patients with WFNS V,

but coiling may proceed Improvement in grade

may make the patient eligible for aneurysmal

clipping

N E U R O I M AG I N G A N D

L A B O R AT O RY   T E S T S

Subarachnoid hemorrhage shows on CT scan

(Figure  26.3a and b) Some patients show CT

scans with massive SAH and early global edema

(Figure  26.3c and d).27 CT perfusion may show

reduced blood flow These findings are more common in patients who remain comatose after cardiopulmonary resuscitation When CT scan

is done within hours after the event, the tivity in aneurysmal SAH is very high and may approach 95% In 2%– 5% of the patients, sub-arachnoid blood has completely “washed out” on

sensi-CT scans within 24 hours, but more likely, sensi-CT may have missed a thin layer of blood Repeat CT scan in patients with initial “negative CT” and xanthochromia often documents traces of SAH in sulci or ventricles.54

FIGURE  26.3: Subarachnoid hemorrhage (a, b) Subarachnoid hemorrhage with complete filling of the basal

cis-terns and fissures (arrows), creating a “crab- like” cast (c)  Global cerebral edema (d)  Extensive low- attenuation changes (arrows) in frontal and insular cortex.

Part VII: Management of Specific Disorders

322

Fisher developed one of the first grading

sys-tems for SAH The Fisher scale, although deeply

ingrained in neurological practice, remains a

gross estimate of the amount of subarachnoid

blood, and it has significant inter- observer

vari-ability This scale, currently modified (Table 26.2),

emphasizes the presence or absence of a thick clot

and the presence of intraventricular hemorrhage,

and predicts the development of delayed cerebral

ischemia.53

Another grading system was developed by

Hijdra and colleagues78 (Table 26.2) A sum score

of greater than 20 is considered predictive of cerebral vasospasm In our recent study of dif-ferent scales, we found the Hijdra scale superior

to other scales in prediction of cerebral spasm.49 Quantification of SAH and calculation of volume may remain a useful alternative, but the applicability of this method remains unknown Grading after “resuscitation” correlates better with outcome.59

vaso-Important information can be gathered by careful inspection of CT scans The distribution of the subarachnoid blood on CT scan may suggest the location of the aneurysm, but despite subtle differences, CT scanning often cannot reliably pre-dict the location of the aneurysm There is no cor-relation between the size of the aneurysm and the amount of SAH.140 Generally, patients with diffuse distribution of blood in cisterns and fissures often have a basilar artery or ACA aneurysm However, patients with a concentration of blood in the inter-hemispheric fissure may have an aneurysm of the anterior cerebral artery, and patients with cister-nal blood surrounding the perimesencephalic cis-terns most likely harbor a basilar artery aneurysm Likewise, sylvian fissure hemorrhages are mostly from an aneurysm of the MCA

The additional presence of an intracerebral hematoma, however, has more localizing value Hematomas may be found in the frontal lobe (anterior communicating artery aneurysm), in the medial part of the temporal lobe (internal carotid artery aneurysm), and within the sylvian fissure extending into the temporal lobe (MCA aneu-rysm) (Figure 26.4).73

As alluded to earlier a benign form of SAH has been reported in which bleeding is confined

to the cisterns in front of the brainstem without evidence of an aneurysm in the posterior cerebral

circulation— so- called pre- truncal SAH141,142,170

(also called perimesencephalic hemorrhage)159

(Figure  26.5a) True perimesencephalic orrhages are purely traumatic, due to either a P2 aneurysm or spinal dural arteriovenous fis-tula.141,146 Typically, in these variants, blood clots

hem-do not extend to the lateral sylvian fissures or to the anterior interhemispheric fissure Some exten-sion to the basal part of the sylvian fissure is pos-sible when CT scanning is performed very early Intraventricular hemorrhage is absent except for some sedimentation in the posterior horns Magnetic resonance imaging (MRI) is helpful in localizing the blood clot in front of the brainstem, and no cause has been found with this modality (Figure 26.5b) MRI of the cervical spine has also been unrevealing.170

TABLE 26.2. COMPUTED TOMOGRAPHY

FINDINGS IN THE MODIFIED FISHER

AND HIJDRA SCALE

1 Focal or diffuse thin SAH without IVH

2 Focal or diffuse thin SAH with IVH

SAH: subarachnoid hemorrhage; IVH: intraventricular hemorrhage.

Data from Kistler JP, Crowell RM, Davis KR, et  al The relation

of cerebral vasospasm to the extent and location of

subarach-noid blood visualized by CT scan: a prospective study Neurology

1983;33:424– 436; and Frontera J, Claassen J, Schmidt JM, et  al

Prediction of symptomatic vasospasm after subarachnoid

hemor-rhage: the modified Fisher scale Neurosurgery 2006;59:21– 27.

C D

F

A

D

Hijdra method of grading subarachnoid hemorrhage

identifies 10 basal cisterns and fissures:  (A)  frontal

interhemispheric fissure; (B)  sylvian fissure, lateral

parts both sides; (C)  sylvian fissure, basal parts both

sides; (D)  suprasellar cistern both sides; (E)  ambient

cisterns both sides; and (F) quadrigeminal cistern The

amount of blood in each cistern and fissure is graded 0,

no blood; 1, small amount of blood; 2, moderately filled

with blood; and 3, completely filled with blood The sum

score is 0 to 30 points 78

(a) (a1) (a2)

tomo-is needed.

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 325

The cause of this perplexing benign form of

nonaneurysmal SAH remains unclear Prior

spec-ulative explanations have included spinal dural

arteriovenous fistula, rupture of a dilated vein in

the prepontine cistern, and intramural

dissec-tion,72,141,171 but there is accumulating evidence

that a small blister- like aneurysm of the posterior

circulation may be implicated Recent 3D cerebral

angiograms have been able to document these

small lesions.166

Pretruncal hemorrhage may closely mimic a

ruptured basilar artery or dissecting P1– P2

aneu-rysm, and therefore a four- vessel cerebral

angio-gram is warranted.93 In our experience and that of

others,126 we have found small (dissecting)

aneu-rysms occasionally on repeat studies; and repeat

cerebral angiograms on CTA may remain

war-ranted in this subset

Localized blood in the sulci alone is unusual in

aneurysmal SAH and often indicates trauma

coag-ulopathy or, much less common, vasculitis.104,136

Subarachnoid blood caused by trauma is most often

confined to the vertex and superficial cortical sulci

or accumulates in the ambient cisterns at the level

of the tentorium.40 Computed tomography scans

should be scrutinized for fractures on bone

win-dows when physical examination shows other signs

of trauma, for example, skin bruising or a soft- tissue

swelling When blood is in the sylvian fissure, a

reli-able distinction from a ruptured middle cerebral

aneurysm cannot be made on clinical grounds or by

CT scan, and cerebral angiography is needed

Intraventricular blood on CT scans signals a

severe SAH Aneurysms of the ACA have a

pro-clivity to perforate the lamina terminals and enter

the ventricular system Massive intraventricular

hemorrhage in patients with SAH may also

sug-gest rerupture Subdural hematomas are seen

in 1% of patients with SAH, often with cisternal

blood, and very rarely in isolation Most often, a

carotid artery (ophthalmic or posterior

commu-nicating) aneurysm can be demonstrated on the

angiogram

An important feature on CT scanning is acute

hydrocephalus Enlargement of the lateral

ventri-cles is often asymptomatic in acute SAH, and acute

hydrocephalus as an explanation for drowsiness is

more convincing if progression on sequential CT

scans can be demonstrated or if the ventricles are

very plump (Chapter 36)

Cerebral angiography remains the

unchal-lenged gold standard for the diagnosis of cerebral

aneurysm One can argue for early four- vessel

cerebral angiography in every patient, including

those with poor- grade SAH These patients may have aneurysms that can be occluded through endovascular techniques

Before cerebral angiography is undertaken, serum creatinine concentration should be deter-mined The risk for neurologic deficit associated with the procedure is 0.07%.29 The most impor-tant risk factor for contrast- induced nephrotox-icity is preexisting renal failure The risk is also increased in patients with reduced intravascular volume and in patients using drugs that impair renal responses, such as angiotensin- converting enzyme inhibitors and nonsteroidal anti- inflammatory drugs In patients with preexisting renal impairment, defined as a creatinine value

of more than 1.8 mg/ dL, 0.45% saline should be given intravenously at a rate of 1 mL/ kg of body weight per hour beginning 12 hours before the scheduled angiography.29,74

Cerebral angiography may demonstrate aneurysms at typical locations (Figure 26.6) Standard examination should include antero-posterior and lateral views, but because over-lapping is significant, oblique views are often necessary The neuroradiologist may be guided

by the findings on CT scan and should quently use additional oblique views in evalu-ating the circle of Willis Important additional views are submentovertex views (particularly useful for demonstrating the neck of an anterior communicating aneurysm) and transorbital projection (neck of the MCA) Towne’s pro-jection is important to visualize the tip of the basilar artery Failure to demonstrate an aneu-rysm may be related to inadequate projection

fre-or incomplete study (three- vessel study), and a second angiogram at a slightly different angle may uncover an aneurysm Three- dimensional image volume generated by digital fluorography with rotational image acquisition has improved detection Multiple aneurysms may be found, and it is virtually impossible to predict which aneurysm has bled However, additional clues (next to CT scan patterns) may be present, such as irregularity of the wall of the aneurysm produced by the sealing clot, vasospasm in the vicinity of the aneurysm, and size between 5 and 15 mm

When an angiogram is negative, a second bral angiogram may demonstrate an aneurysm in approximately 10% of cases The second cerebral angiogram should be particularly carefully scruti-nized for a posterior circulation aneurysm, which could have been “missed” on the first angiogram

cere-Part VII: Management of Specific Disorders

326

Whether exploratory craniotomy is needed in

patients with a high suspicion of an aneurysm

(presence of subarachnoid blood and intracranial

hematoma) is very unclear and this is rarely done,

even though some explorations have been

suc-cessful in detecting the ruptured aneurysm.41

CT angiogram has been used in patients with

large aneurysms to better document

anatomi-cal configuration,71,176 in patients with an

ini-tial negative cerebral angiogram (as a means of

follow- up), and as the only additional

diagnos-tic test in patients with pretruncal SAH in some

European centers.162 Its place in the diagnostic

evaluation of patients with an SAH is unclear

Moreover, the less than perfect sensitivity of

97% (87% in aneurysms, 3 mm) and specificity

of 86% may have medicolegal implications if it is

the only study done Moreover, anatomic bulges

of the basilar tip and pituitary stalk mistaken for aneurysms and incorrect three- dimensional reconstruction of overlapping MCAs are some

of the reasons for false- positive results The role

of CT angiogram largely is as a simple and quick (but also expensive) method to demonstrate or exclude an aneurysm CT angiogram, there-fore, has been performed during night hours while waiting for a more definitive study in the morning

Magnetic resonance imaging is usually not sensitive for SAH but may be able to show SAH when fluid attenuation inversion recovery (FLAIR) sequences are used Recirculation of bloody cere-brospinal fluid (CSF) over the convexity is com-monly seen as well MRI may be important in

Anterior cerebral Anterior choroidal Posterior parietal Pericallosal

artery

Ascending frontal

Vertebral artery Basilar artery

Posterior cerebral artery

Superior cerebellar branches

Calcarine and occipital branches

parieto-PICA

Anterior temporal Ophthalmic Internal carotid

Frontopolar artery

Callosomariginal artery

Orbital-frontal artery

Ophthalmic

Pericallosal artery Internal frontoparietal branches

Internal carotid with MCA branches removed

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 327

demonstrating an acute SAH in the posterior fossa,

which, as mentioned previously, may be difficult

to detect on CT scan because of beam- hardening

artifacts Often, in retrospect, CT scans showed a

similar blood clot Sometimes a small deposit of

blood in the sylvian fissure not visualized on CT

scans can be demonstrated on MRI

Magnetic resonance angiography (MRA) is equally useful in demonstrating the aneurysm,

and with three- dimensional time- of- flight MRA,

aneurysms 3 mm in diameter and larger can be

demonstrated

F I R S T S T E P S

I N   M A N AG E M E N T

Initial management in patients with

aneurys-mal SAH can be adapted to the initial grade

Subarachnoid hemorrhage of WFNS grade I  to

III should be differentiated from poor- grade SAH

(WFNS grade IV or V), assuming that the poor

clinical grade is caused by the initial impact alone

The initial management in aneurysmal SAH is summarized in Table 26.3 Continuous assessment

of alertness and performance remains important Experienced nurses in neurologic intensive care usually are familiar with the peak time of cere-bral ischemia and the first clinical signs of acute hydrocephalus

An important component of management in SAH is the relief of pain Severe headache is best treated by acetaminophen with codeine Many patients benefit from the calming effect of these agents, but others do not tolerate opioids and may vomit excessively Codeine remains effective in many patients Tramadol (usually only in its maxi-mal dose of 400 mg/ day) may be helpful in this situation but should be avoided if the patient had a seizure at onset In patients with marked neck stiff-ness and severe unrelenting headache, 4 mg of dexa-methasone for a few days may do wonders in some.Respiratory care is largely supportive, and serial chest radiographs should be reviewed for signs of gastric aspiration or pulmonary edema Intubation and mechanical ventilation are often indicated in poor- grade SAH The venti-latory mode chosen should provide adequate

TABLE 26.3. INITIAL MANAGEMENT OF ANEURYSMAL SUBARACHNOID

HEMORRHAGEAirway management Intubation if patient has hypoxemia despite facemask with 10 L of 60%– 100%

oxygen/ minute, if abnormal respiratory drive or if abnormal protective reflexes (likely with motor response of withdrawal or worse)

Mechanical ventilation IMV/ PS

AC with aspiration pneumonitis, ARDS or early neurogenic pulmonary edemaFluid management 2– 3 L of 0.9% NaCl per 24 hours

Fludrocortisone acetate, 0.2 mg b.i.d orally, if patient has hyponatremiaBlood pressure management Aim at SBP of < 160 mm Hg

IV labetalol 10– 15 mg every 15 min if neededHydralazine 10– 20 mg IV if bradycardia

Blood glucose control (goal 140– 180 mg/ dL)

SC heparin 5,000 U t.i.d after clipping or coiling of aneurysm

GI prophylaxis: pantoprazole 40 mg IV daily or lansoprazole 30 mg orally through nasogastric tube

Other measures Nimodipine, 60 mg six times a day orally for 21 days

Tranexamic acid 1 gram IV, second dose 2 hours later, third dose 6 hours later

if delayed clipping or coilingCodeine 30– 60 mg orally every 4 hours as neededTramadol, 50– 100 mg orally q4h, for pain managementLevetiracetam 20 mg/ kg IV over 60 minutes; 1,000 mg b.i.d maintenance (if seizures have occurred)

Access Arterial catheter to monitor blood pressure (if IV antihypertensive drugs

anticipated)Peripheral venous catheter or peripheral inserted central catheter

ARDS, acute respiratory distress syndrome; DVT, deep vein thrombosis; GI, gastrointestinal; IMV, intermittent mandatory ventilation; IV, intravenously; MAP, mean arterial pressure; NaCl, sodium chloride; PS, pressure support; SBP, systolic blood pressure; SC, subcutaneously.

Part VII: Management of Specific Disorders

328

minute ventilation at the lowest possible airway

pressure— in most instances, an intermittent

mandatory ventilation mode

Stress cardiomyopathy tends to develop in

patients with poor- grade SAH, and it can be

observed clinically and on repeat echocardiograms

It may be a cause for the development of pulmonary

edema (Chapter 46)

To provide adequate fluid intake is an essential

part of the management of SAH Approximately

one- third of the patients have a decrease in plasma

volume of more than 10% in the first days, often

detected by negative fluid balance.173 Initially,

most patients are probably best managed with 3

L of isotonic saline (or infusion of 125 mL/ hr)

Fever (> 38.5°C) is more common in poor- grade

intubated patients, but fever is also associated,

in the absence of any infection, with the

devel-opment of cerebral vasospasm after other causes

have been excluded Fever is typically controlled

aggressively, and different methods are available3

(Chapter 21)

The management of acute hypertension after

SAH is uncertain18 (Chapter 19) When using

anti-hypertensive treatment, a fine line separates

neces-sity from harm A retrospective study suggested that

the incidence of cerebral infarction is increased in

patients treated with antihypertensive drugs (largely

clonidine).172 On the other hand, earlier studies

sug-gested that rebleeding and death from rebleeding

are increased in patients with persistently increased

systolic blood pressures (Chapter 19) Given the lack

of evidentiary data, there is insufficient guidance for

antihypertensive management soon after

aneurys-mal subarachnoid hemorrhage

Most practicing neurointensivists and

neuro-surgeons decrease blood pressure with

intrave-nous labetalol when a mean arterial pressure of

approximately 120 mm Hg or systolic blood

pres-sure of 180 mm Hg persists

Patients with SAH may be combative and may

require sedation Agitation may be directly related

to placement of the endotracheal tube and to

inappropriate mechanical ventilator settings (e.g.,

high- frequency assist- control in an alert patient)

Not infrequently, these patients can be extubated

without any difficulty, which resolves the distress

and agitation Combative and agitated patients

can be best treated with low- dose midazolam or

propofol infusion

Nutrition can usually be deferred until the

sec-ond day Enteral feedings in patients with critical

neurologic illness are not always tolerated, and

poor gastric emptying may lead to aspiration

However, placement of a nasoenteric feeding tube

into the duodenum or jejunum may overcome these problems Usually, concentrated commer-cial solutions infused at a low rate are adminis-tered (see Guidelines)

Stool softeners are prescribed, particularly for patients who regularly require opiates Prophylaxis

of deep vein thrombosis is provided by stockings and pneumatic compression devices Proton- pump inhibitors are provided only for patients who have a history of gastric ulcers or who have been using nonsteroidal anti- inflammatory agents

or aspirin and in patients on the mechanical tilator Patients who have a decreased level of consciousness need an indwelling bladder cath-eter The use of intermittent catheterization may decrease the incidence of urinary tract infection, but the procedure is too stressful for patients with acute SAH

ven-Nimodipine is administered in all patients with SAH to prevent delayed cerebral isch-emia.2,5,130 It can be crushed and applied through the nasogastric tube.2 A regimen of nimodipine (60 mg orally every 4 hours) is instituted for 21 days on the basis of significant reduction in the incidence of delayed cerebral ischemia and mor-tality.2,132 A review of 90 patients treated with nimodipine for 15 days or less did not suggest an increase in delayed cerebral ischemia, but there

is no reason to shorten the period of tion.153 Nimodipine can be discontinued when cerebral angiogram shows no aneurysm No other agents have been found to reduce cerebral isch-emia.66,67 There was interest in the use of statins following SAH Cholesterol- lowering agents may also prevent thrombogenesis, increase cerebral arterial diameter, and reduce inflammation Only small studies have been performed, and there were early indications of a possible benefit.116,149,155

administra-The Simvastatin in Aneurysmal Subarachnoid Hemorrhage (STASH) trial, however found no benefit.98

The use of prophylactic antiepileptic tion is very questionable The incidence of seizures after acute SAH is low, and most seizures recur during re- rupture The risk of late seizures may theoretically be increased in patients who have

medica-a tempormedica-al lobe or frontmedica-al lobe hemmedica-atommedica-a medica-and large amounts of blood on CT, but again, no hard data are available to specifically justify prophylac-tic antiepileptic agents Newer studies raised the possibility of worse cognitive outcome after the use of phenytoin.127 The underlying mechanism

is unclear and could be related to a cal interaction between phenytoin and nimodip-ine (phenytoin may reduce bioavailability of

pharmaceuti-Chapter 26: Aneurysmal Subarachnoid Hemorrhage 329

nimodipine through induction of the hepatic

cytochrome P450 isoenzymes)

Currently, antifibrinolytic therapy is not used

routinely Antifibrinolytic therapy is very

effec-tive in preventing rebleeding and significantly

reduces the risk of rebleeding.83 However, when

used for prolonged periods of time, a reciprocal

increase in delayed cerebral ischemia is observed

and results in no overall benefit.163 A pilot study in

which tranexamic acid was given for only 4 days

produced the reverse of the desired result, with

no effect on the incidence of rebleeding and an

increase in the incidence of cerebral ischemia.168

Use of antifibrinolytic agents varies among

institutions and among neurosurgeons There is

a tendency to use a few doses of antifibrinolytic

drugs in recently admitted patients while they

await the planning of surgical repair or

endovas-cular coiling.26

Emergency or early surgery is indicated in

patients with evidence of rebleeding or intra-

cerebral hematoma in the temporal lobe and

tissue shift12 and, at the opposite end of the

spec-trum, any patient in good prior health with WFNS

grade I– III.13 Surgery can be temporarily withheld

in patients in WFNS grade IV or V with packed

intraventricular hemorrhage and hydrocephalus

Ventriculostomy could produce improvement

in such patients Surgery may also be postponed

in patients with early symptomatic vasospasm,

but the timing of surgery has always remained

contentious

For eligible patients, cerebral angiography

should be performed as soon as feasible and should

be followed by surgical clipping of the aneurysm

(operative techniques and neuro- anesthesia are

beyond the scope of this book) A  cooperative

study group found in a large survey that no major

differences existed between early and late surgery

but that outcome was worse when surgery was

performed between days 7 and 10.95

The development of detachable coils

(Guglielmi detachable platinum coils) has

dramat-ically modified practices.14,19,38,107,123,152,165 A direct

electrical current disconnects the coil, and the

positive electrical charge increases thrombus

for-mation The procedure of multiple coil placement

is time- consuming, taking several hours, and

needs general anesthesia monitoring Coil

place-ment has become the first consideration in most

patients with a ruptured aneurysm, irrespective of

the WFNS grade.7,11,100 It is often the first choice

of treatment in basilar artery apex aneurysms

because clipping is more complicated and risky.64

In the International Subarachnoid Aneurysm

Trial (ISAT) study,96,122 results found benefit from the use of coils in good- grade patients with small anterior circulation aneurysms, but no sufficient proof in other patients with SAH At 1 year, coil-ing was superior, with a 7.4% absolute risk reduc-tion in mortality and major disability At 5 years, mortality in the endovascularly treated group was lower than in the surgically treated patients (11% versus 14%) There was no difference in disability between the groups.124

Large series of patients from France reported good outcomes in endovascularly treated patients, many with poor- grade SAH.11 The generalizabil-ity of the ISAT trial has been questioned, most recently by a study from the University of Toronto that suggested worse hemorrhage- free survival

of coiling compared with clipping.127 Long- term outcome is not yet available, and concern about imperfect repair with coiling remains A  review

of 509 patients with treated ruptured aneurysms found ischemic complications in 7% and aneu-rysm perforation in 3%, with procedure- related mortality of 1%.14 The estimated morbidity related

to the technique was 9%, with an overall ity of 6%, but these numbers are now likely lower with improved skills.14 A considerable drawback

mortal-of endovascularly treated patients is rebleeding from a remnant aneurysm, with reported rebleed-ing rates of 6%– 25%

Experience with endovascular coil placement

in acute ruptured aneurysm is currently tial, but the decision to “clip or coil” remains arbi-trary In the ISAT trial, the inclusion of patients required that both the neurosurgeon and neuro-interventionalist considered the patients eligible for both treatments However, in this trial122 the involved physicians did not agree with each other

substan-in more than two- thirds of cases Currently it can be estimated that more than 70% of ruptured aneurysms are treated endovascularly in US refer-ral centers

Certain criteria have emerged that are based

on the width of the neck and the size and tion of the aneurysm Selection for coiling is often determined by location of the aneurysm

loca-in the posterior circulation, width of neck less than 5  mm, and a dome- to- neck ratio greater than 2 (Figure 26.7) There is a sharp reduction

in the rate of complete persistent occlusion for aneurysms greater than 10 mm in diameter and

in aneurysms with broad necks However, some

of these aneurysms with complex anatomy can

be treated with stent- assisted coiling or balloon- modeling techniques in which a soft balloon

is temporarily inflated in the parent artery to

Part VII: Management of Specific Disorders 330

hold coils within the aneurysm cavity.105,167 The

endovascular techniques are evolving (hydrogel-

coated and bioactive coils106), but the rate of

com-plete occlusion (50%– 70%) remains frustratingly

low The current coiling materials have been

recently reviewed,105,167 but a comprehensive

discussion is outside the scope of this chapter

Many types of cerebral aneurysms can be coiled,

but middle cerebral bifurcation aneurysms often

have arterial branches arising from the sac,

making coiling hazardous The neurosurgeon is

able to avoid these branches by carefully

mod-eling and clipping the aneurysm (Figure 26.8)

Platinum coil placement is illustrated in Figure

26.9, and clipping is shown in Figure 26.10 More

recently, a pipeline embolization device has been

used in complex (dissecting, blister, or

dysplas-tic) aneurysms; but to use this technology (and

its complications) in acute aneurysmal arachnoid hemorrhage is not fully known, and many neurointerventionalists would use it later for secondary repair of partially occluded giant aneurysms Clopidogrel and aspirin are needed

sub-to avoid occlusion of the device and massive cerebral infarction.24,36

D E T E R I O R AT I O N : C AU S E S

A N D M A N AG E M E N T

Most often, patients with SAH are prone to oration from delayed cerebral ischemia,68 rebleed-ing, acute hydrocephalus, and enlargement of a temporal lobe hematoma.164

deteri-Delayed cerebral ischemia or symptomatic vasospasm is manifested by a gradual decrease

in the level of consciousness in most patients,77,80

and in some is associated with hemiparesis, mutism, and, less frequently, apraxia Unusual presentations, such as paraparesis, have been described.62 Patients with delayed cerebral isch-emia may become apathetic, cut short answers to questions, and have initial weakness of one leg or both legs, indicating infarction in both territo-ries of the anterior cerebral arteries.62 However, cerebral infarcts may appear without apprecia-ble clinical signs.147 Delayed cerebral ischemia may cause sudden deterioration and coma, and then often massive brain swelling, and bihemi-spheric infarction is detectable on a repeat CT scan Early recognition of the decrease in level

of consciousness remains crucial Patients have

a fluctuating level of consciousness:  days with daytime sleep and being barely arousable, inter-mingled with days of appropriate behavior and better responsiveness Risk factors for delayed cerebral ischemia include a large number of cis-ternal and ventricular clots (mostly on the first

CT scan),15,48 poor WFNS clinical grade, glycemia, and early surgery.34 The incidence of

hyper-FIGURE 26.8: Middle cerebral artery aneurysm (arrow)

with multiple branches.

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 331

FIGURE  26.9: Successful endovascular coil placement in anterior cerebral artery (ACOM complex) aneurysm

(arrow).

cerebral vasospasm in patients who have

endo-vascular treatment is not known exactly, but our

review suggests significantly less symptomatic

vasospasm than that which occurs with clipping

of the aneurysm.134 Additional laboratory testing

(e.g., transcranial Doppler ultrasonography, CT

perfusion, or cerebral angiography) may confirm

cerebral vasospasm

Diffusion- weighted MRI can detect

abnormal-ities and a reduction in diffusion coefficients It is

unknown whether these abnormalities are

poten-tially reversible with therapeutic intervention

Currently, limited experience suggests a role in the diagnosis of delayed cerebral ischemia Studies have shown scattered multiple hyperintense sig-nals highly consistent with the diffuse nature of cerebral vasospasm

One study reported the use of diffusion- weighted MRI in patients with vasospasm All 10 patients with Doppler- confirmed vasospasm had diffusion- weighted imaging abnormalities, whereas four control patients without vasospasm had no such abnormali-ties Interestingly, seven of the 10 patients with vasospasm were asymptomatic, and some of the diffusion- weighted abnormalities were reversible.32 Another modality that may become clinically useful is CT perfusion.37

However, the definition of hypoperfusion, despite use of color maps, remains unclear There is insufficient data to use CT perfusion

as guidance for hemodynamic augmentation

We recognize the difficulties in the timely acquisition of these tests

The management of cerebral vasospasm has been guided by a medical attempt first and then, almost simultaneously, a cerebral angiogram and endovascular intervention if severe vasospasm can be demonstrated Current published data

on the best approach are unconvincing because systematic measurements of variables are lack-ing, with different methods used in each of the cohorts The areas of uncertainty are the timing

of hemodynamic augmentation, the variable to

be augmented (perfusion pressure or cardiac

FIGURE  26.10: Aneurysmal clip Clipping of

aneu-rysm on 3D cerebral angiogram.

Part VII: Management of Specific Disorders

332

output), the management of a concomitant

cere-bral salt- wasting syndrome,172,173 and the

tim-ing of endovascular procedures.109– 111,119 One

such protocol is outlined in Table 26.4, and we

summarize our approach with euvolemic

hyper-tension Maintenance of intravascular volume

expansion can be enhanced by fludrocortisone

acetate 0.2 mg orally twice a day The fluid

bal-ance is carefully calculated every hour and

scru-tinized for changes in urinary output Weight

change is essentially equivalent to change in

body water, and therefore the daily availability of

body weight is useful in adjusting fluid intake

Commonly used hemodynamic agents are shown

in Table 26.5

Particular care is warranted in patients with significant EKG changes, and induced hyperten-sion may possibly trigger cardiac arrhythmias.When patients do not rapidly improve with these measures, we proceed with a cerebral angiogram Angioplasty can be considered if adequate volume expansion has not resulted in marked clinical improvement Cerebral vaso-spasm can be arbitrarily categorized as mild, moderate, or severe with 50% luminal narrowing Focal cerebral vasospasm indicates vasospasm

in one cerebral artery; in diffuse cerebral spasm, multiple vessels are involved Angioplasty

vaso-of focal spastic segments is a potentially effective treatment for cerebral vasospasm Neurologic

TABLE 26.5. COMMONLY USED HEMODYNAMIC AGENTS

BP, blood pressure; CO, cardiac output; SVR, systemic vascular resistance (Also see appendix for titration schedule.)

TABLE 26.4. PROTOCOL FOR EUVOLEMIC HYPERTENSION IN THE TREATMENT

OF CEREBRAL VASOSPASM IN ANEURYSMAL SUBARACHNOID HEMORRHAGE

SAH, clinically asymptomatic but TCD or CT (angiogram or perfusion) evidence of diffuse cerebral vasospasm

Obtain hourly readings of fluid balance and body weight

Accomplish volume repletion with crystalloids

Avoid antihypertensive and diuretic agents

SAH, secured aneurysm, clinical evidence of cerebral vasospasm

Notify neurointerventionalist for possible cerebral angiography

Give crystalloid bolus or albumin 5%

Match fluid input with urine output

When urine output is > 250 mL/ hr, start administration of fludrocortisone acetate, 0.2 mg b.i.d

Concurrently start administration of IV phenylephrine, 10– 30 μg/ min, with increase in MAP 25% above

baseline or > 120 mm Hg (a central access is secured)

Start administration of IV dobutamine, 5– 15 μg/ kg/ min if no response

Consider replacing phenylephrine with norepinephrine if no response

Perform cerebral angiography for angioplasty or intra- arterial infusion with verapamil

CT, computed tomography; MAP, mean arterial pressure; SAH, subarachnoid hemorrhage; TCD, transcranial Doppler ultrasonography.

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 333

improvement has been reported in 60%– 70% of

patients who did not have a response to

hyper-volemic hypertensive treatment, but these results

seem too optimistic

Angioplasty of the major cerebral

arter-ies is performed with a silicone balloon

cath-eter.33,50,51,91,102,108 After proper placement, the

balloon is gently inflated to one atmosphere and

almost immediately deflated and advanced 1 cm

to the next segment The technique most

com-monly used is shown in Figure 26.11 The middle

cerebral, anterior cerebral, posterior cerebral,

and vertebral arteries are eligible for angioplasty

More distal arteries are technically accessible,

but the risk of rupture from overextension is

real Angioplasty of a feeding artery of a recently

ruptured aneurysm is contraindicated unless the

aneurysm is secured first with coils or clips Risk

of rupture of the artery itself is low, but rupture

may occur with overdistention or distal placement

in the artery.114 Except for this caveat, most

neu-rointerventionalists treat all accessible vasospastic

arteries at once.178

Histopathologic studies showed that

compres-sion and expancompres-sion of the intima caused

consid-erable stretching of the vessel to diameters larger

than original.86 Intimal damage appeared mal Angioplasty can be performed without major complications Virtually no patients have subse-quent infarcts in the territory of the perforators of the MCA, most likely because there is no intimal damage

mini-Several intra- arterial agents have been used in small groups of patients and have shown variable success (Table 26.6) The main objective against its use is a temporary effect (not more than 24 hours) of any of the vasodilating agents and safety concerns, particularly papaverine,31,76 result-ing in myocardial depression and suppression of

FIGURE 26.11: Technique of angioplasty.

TABLE 26.6. INTRA- ARTERIAL AGENTS

TO IMPROVE CEREBRAL VASOSPASM

Arteries vs ClinicalPapaverine85 2 hours 43% vs n/ aVerapamil52 7 hours 44% vs 33%

Nicardipine4,150 16 hours 60% vs 91%

Nimodipine9 9 hours 43% vs 76%

n/ a = not available.

Part VII: Management of Specific Disorders

334

the AV and SA node Most institutions now use

intra- arterial verapamil or nicardipine, either

selectively or in the carotid artery (Figure 26.12)

Some groups92 have advocated multiple

papav-erine infusions with a follow- up angiogram 24

hours later, followed by repeat infusions (up to

three infusions on consecutive days), but

papav-erine is out of favor with most interventional

neuroradiologists.6,30,94,115

Failure to reverse clinical deficits most

com-monly indicates cerebral infarction Computed

tomography scanning may be helpful but, if done

early, may give only a limited view of the area that

is infarcted Not infrequently, only a single arterial

territory appears affected, but multifocal

infarc-tion may become apparent on subsequent CT

scans or at autopsy.135 (One should be aware that

multiple small hypodensities on CT scan,

par-ticularly in the cerebellum, thalamus, and cortical

areas, may be related to complications from bral angiography.89) Mass effect from large hemi-spheric infarction may occur and often is fatal Temporal lobectomy may salvage the patient but

cere-at the price of severe disability It may be an option only in young patients

The risk of rebleeding after the first ture is approximately 30% in the first month Larger aneurysms are at higher risk for rebleed-ing (possible cutoff of 10 mm).10 Early placement

rup-of ventriculostomy in patients not treated with antifibrinolytics157 was a major risk factor in one study not ours.120 Many patients rebleed within hours after the first bleeding.58,81,97 The clinical presentation of re- rupture can be dramatic and could involveare loss of consciousness associated with loss of several brainstem reflexes, includ-ing pupillary light response and oculocephalic responses In most patients, respiratory arrest or

FIGURE  26.12: Two patients with symptomatic cerebral vasospasm Upper row: Some improvement of cerebral vasospasm with intra- arterial verapamil Lower row: Marked improvement with angioplasty.

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 335

gasping breathing occurs, necessitating

immedi-ate endotracheal intubation and mechanical

ven-tilation.82 Computed tomography scanning very

often demonstrates fresh blood, more common in

the ventricular system (Figure 26.13), or less often

a new intracerebral hematoma that causes marked

brain tissue shift Recovery from rebleeding is

dif-ficult to predict, but many patients begin to trigger

the ventilator within hours, and recovery is also

signaled by a return of brainstem reflexes These

patients may improve rapidly, up to the point of

self- extubation Rebleeding can be much less

dramatic in patients presenting with acute

head-ache alone In some fortunate patients, rebleeding

begins with sudden emergence of fresh blood in

the collection bag of the ventricular drain, and

rapid evacuation of intraventricular blood is often

life- saving More subtle presentation are possible

with patients complaining of a worsening

head-ache after headhead-ache had subsided or became more

tolerable New onset and transient focal signs

maybe observed

Management of rebleeding is essentially

sup-portive Emergency clipping or coiling of the

aneurysm must be strongly considered, since

most patients will have a second rebleed, which

is associated with high mortality The initial

mortality of rebleeding is 50% The total mortality from rebleeding and from complications associ-ated with persistent coma is 80% in 3 months.81

Patients with a devastating rebleed may progress

to brain death This clinical course is most likely

in patients with massive hydrocephalus and tricles packed with blood clots

ven-The clinical presentation of acute lus is characterized by progressive impairment of consciousness.45,70,158 Patients become much more drowsy, tachypneic, and may not be able to protect the airway or cough up secretions Most patients cannot follow complex commands, and only vig-orous pain stimuli will open the eyes and cause localization of a pain stimulus Pinpoint pupils and downward deviation of the eyes may develop, most often in patients with dramatic enlargement

hydrocepha-of the ventricular system The diagnosis hydrocepha-of acute hydrocephalus becomes clear when serial CT scans show further enlargement of the ventricular system

Placement of a ventricular drain is indicated

in patients with intraventricular blood and cal deterioration It has been suggested that the risk of rebleeding is increased in patients with ventricular drainage Our study in SAH failed to show an increased incidence of rebleeding when

FIGURE 26.13: Two examples of rebleeding Initial hemorrhage (a, b) Rebleeding (c, d); note new blood in

ven-tricles (arrows) Initial SAH with worsening hemiparesis soon after admission (e) Contrast CTA shows contrast

leakage (f) Cerebral angiogram shows carotid artery blister (1 mm by 2.5 mm) aneurysm (g).

Part VII: Management of Specific Disorders

336

preoperative ventriculostomy was done within 24

hours after SAH before aneurysmal repair.120

Ventriculostomy is often performed when

enlarged hemoventricles are present in comatose

patients, but we have not often seen dramatic

improvement in patients with loss of upper

brain-stem reflexes Late hydrocephalus may be more

common in patients with intraventricular casts,

and 20%– 50% may need a permanent shunt.23

The external ventricular drainage (EVD) is kept

open at 10 cm above the external auditory canal

or lower if no clinical improvement is seen after

CSF drainage the first day of placement

Increased intracranial pressure is common

in SAH from edema in severe cases or due to

acute hydrocephalus.177 Acute hydrocephalus

may also be managed with placement of a lumbar

drain.84,117 Contraindications are summarized in

Table 26.7 Placement is simple through a lumbar

puncture needle, but may need fluoroscopy84

(Figure 26.14) The collection chamber is placed

at the level of the shoulder and CSF of 20 mL or less is drained per hour The collection chamber can be raised to reduce CSF collection It is unre-solved whether lumbar drainage provides better clot removal than ventriculostomies, but one retrospective study found a dramatic threefold reduction in cerebral vasospasm using a lumbar drain However, differences in cerebral vaso-spasm may be related to better ICP control and not blood washout.99 A  prospective study using lumbar drain versus standard therapy reduced ischemia but did not improve outcome.1 We found aggressive CSF diversion improved CBF after lumbar drainage.57 Higher complications were found in one study.128

There are different practices of weaning of the ventriculostomy It can be convincingly argued

FIGURE 26.14: Lumbar drain in situ.

TABLE 26.7. CONTRAINDICATIONS FOR LUMBAR DRAIN PLACEMENT

IN ANEURYSMAL SUBARACHNOID HEMORRHAGEAny hemispheric or extracranial hematoma with mass effect or shift of midline structures

Effacement of the basilar cisterns

Obstructive clot in third or fourth ventricle

Coagulopathy (INR > 1.4)

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 337

that patients with high risk of cerebral vasospasm

should continue to drain CSF to reduce ICP and

to enhance clot removal Acute hydrocephalus

may also reduce cerebral perfusion in the

peri-ventricular white matter and basal ganglia and

somewhat less in cortical areas.156 Therefore,

weaning should be considered in patients only

after 7– 10 days in situ Patients with CSF red

blood cell counts of less than 10,000 cells/ mL,

CSF protein levels less than 40 mg/ dL, and

nor-mal or improving bicaudate and third ventricle

size after 24 hours clamping can be weaned

suc-cessfully In some patients, raising the EVD to 20

cm will develop headaches and increasing ICP,

but multiple attempts in the following days may

still be successful We have used acetazolamide

to reduce CSF production because it inhibits

carbonic anhydrase mediated CSF production

and this can be substantial, up to 50% of normal

CSF production Rapid or slow weaning does

not predict ventricular peritoneal shunt

place-ment Some studies found a higher incidence

of shunt dependency in coiled patients versus

clipped patients, a finding tentatively explained

by clot removal during surgery.39,161 Shunt valves

maintain an instant flow of CSF Flow control

valves with low settings may cause overdrainage,

in particular if it lowers CSF below the

physi-ologic limits (<5 cm H2O) Valve settings can be

programmed (from 3– 20 cm H2O pressures) In

some patients normal pressure hydrocephalus

may occur weeks after subarachnoid

hemor-rhage and low ventriculostomy levels are needed

to maintain drainage Low valve settings or no

valve may be needed to avoid post

ventriculo-peritoneal hydrocephalus

Subarachnoid hemorrhage in a patient

admit-ted with a temporal lobe hematoma, almost

invariably associated with an MCA aneurysm, is

relatively unusual but potentially life- threatening

The hematoma usually is large, and virtually no

blood is present in the cisterns other than the

suprasellar cistern

Acute deterioration with massive

enlarge-ment of the hematoma may occur with

rebleed-ing, most often diagnosed when additional

intraventricular hemorrhage is found Early

neu-rosurgical intervention is indicated and, in

addi-tion to evacuaaddi-tion of the clot, includes repair of

the aneurysm.75 It is difficult to decide whether

patients with drowsiness alone should have

emergency neurosurgical evacuation, but one

may opt for emergency angiography in this

situ-ation and proceed with clipping of the aneurysm

soon after presentation A study of intracerebral

hematoma in aneurysmal SAH showed that intracranial hemorrhage on CT scan alone was more often associated with a poor outcome In another study, rebleeding occurred statistically more often in patients with SAH- associated intracranial hematomas Therefore, patients with intracerebral hemorrhage should be scheduled for early angiographic study and emergency sur-gery The management of temporal lobe hema-toma in the current endovascular era has become more difficult Patients may have the aneurysm secured, but clinical improvement may stall due to mass effect In some of these patients, later evacuation of the temporal hematoma is performed

Subarachnoid hemorrhage may be the first manifestation of a ruptured giant aneurysm Sudden deterioration in a patient with a giant aneurysm may indicate thrombus formation, and extension to the parent vessel may cause infarction.97 Timing of surgery and planning of techniques, including hypothermic cardiopul-monary bypass, may take additional days after admission The management mortality has been estimated to be about 21%, with perioperative mortality reaching 10% Temporary occlusion

of a patent vessel is needed in two- thirds of the cases

A particularly difficult problem arises when a patient’s condition deteriorates in the days after clipping of the aneurysm Drowsiness is com-mon in patients who have had early surgery, and whether lifting and retraction causing swelling of the brain or vasospasm is the cause of neurologic deterioration is clinically difficult to determine Transcranial Doppler ultrasonography or perfu-sion CT scan may distinguish between the two possibilities In patients with postoperative swell-ing, transcranial Doppler ultrasonography find-ings are within normal limits, and most of these patients improve over days

Of all possible systemic complications, natremia is the most common but is seldom a cause of deterioration It is more common in patients with hydrocephalus, particularly enlarge-ment of the third ventricle A mild degree of hypo-natremia (125– 134 mmol/ L) is asymptomatic and self- limiting Severe hyponatremia (< 120 mmol/ L) requires urgent treatment with 3% saline but is very rare after SAH If hyponatremia is persistent, fludrocortisone can be added (Chapter  57).68,174

hypo-Pituitary dysfunction is more common than appreciated.63

An unusual but well- documented cause of sudden deterioration is acute cardiac arrhythmia

Part VII: Management of Specific Disorders 338

with a significant decrease in blood pressure.118

Well- known life- threatening cardiac arrhythmias

are brief ventricular tachycardia, asystole, and

tor-sades de pointes (Chapter 56)

Seizures may cause sudden deterioration, but

most are observed at the initial rupture or during

rebleeding.69 Failure to fully awaken after a

gener-alized tonic- clonic seizure may point to

noncon-vulsive status epilepticus, but again, this cause of

deterioration is very unusual.17

An uncommon cause of sudden deterioration

is pulmonary embolism The risk is increased

after craniotomy and in patients who have leg

paralysis predisposing to deep vein

thrombo-sis (often after clipping of the ACA aneurysm)

Sudden death from pulmonary embolism may

occur in the first 2 weeks after successful clipping

of the aneurysm

In summary, acute, often transient,

deteriora-tion in SAH remains unexplained in 20%– 30% of

patients It is certainly possible that unwitnessed

seizures, drug effects (e.g., from large doses of

opi-oids for pain management), or swelling

surround-ing a parenchymal hematoma can be implicated in

some instances, but the cause often remains elusive

O U T C O M E

Several outcome studies have shown that, in

patients with SAH who reach the hospital, the initial

grade and coma on admission determine outcome

(Figure 26.15).22,132,145 Failure to improve in logic grade within 48 hours in poor- grade SAH (IV

neuro-or V) despite ventriculostomy is associated with

a high likelihood of poor outcome, particularly

in patients with intraventricular hemorrhage and ventriculomegaly Many of these patients die from systemic complications if they do not awaken from coma 2– 3 weeks after admission.35 Many other fac-tors also contribute, such as amount of blood on

CT scan, aneurysm site (particularly the posterior circulation), and size, age, and further neurologic deterioration, all of which determine a less satisfac-tory outcome Poor outcome is likely in patients with early or delayed cerebral edema, but reason-ably good outcome is found in approximately 40%

of patients.27 In several studies, seizures at onset emerged as an independent risk factor for late sei-zures and poor outcome.16,28

Lower hemoglobin concentrations may be associated with worse outcome This association can be explained by more blood samples in poor- grade SAH patients and possibly more aggressive fluid management However, microdialysis and brain tissue oxygen tension data suggest increased brain tissue hypoxemia and a higher lactate/ pyru-vate ratio (indicative of cell energy dysfunction)

in patients already with hemoglobin levels of less than 9 gr/ dL.103

Good clinical grade at presentation, no bral hematoma on CT or later cerebral infarction,

cere-SAH

Alert

Yes No

No Functional

independence Indeterminateor good

outcome

Poor outcome

Improved consciousness after ventriculostomy

or hematoma removal

Cerebral vasospasm

Stupor or coma

FIGURE 26.15: Outcome algorithm Functional independence: No assistance needed, minor handicap may remain Indeterminate: Any statement would be a premature conclusion Poor outcome: Severe disability, persistent vegeta- tive state, or death.

SAH, subarachnoid hemorrhage.

Chapter 26: Aneurysmal Subarachnoid Hemorrhage 339

and absence of severe anemia requiring blood

transfusion all increased the likelihood of

excel-lent functional outcome.129 Patients who have

a supposedly good outcome after SAH could

have neuropsychologic deficits characterized

by disturbed concentration, disturbed mood,

short- term memory lapses, and difficulty with

information processing.65 This condition may

be more prevalent in patients with surgery for

anterior circulation aneurysms In many of these

patients, extensive neuropsychologic battery tests

are needed to demonstrate these findings Mood

changes may remain at 1 year after SAH

Patients with normal angiograms have a much better outcome, but only if they have a

pretruncal pattern on CT scan.138,159 One study

found that patients with normal angiograms and

so- called aneurysmal patterns on CT scan

(dif-fuse localized blood in all cisterns rather than

more focal perimesencephalic hemorrhage) did

as poorly as patients with aneurysmal

hemor-rhage, whereas patients with pretruncal

nona-neurysmal hemorrhage did not have any major

cognitive deficits, rebleeding, or delayed

cere-bral ischemia.137

Recent follow- up data of the ISAT trial revealed after 1  year higher mortality in coil-

ing (10% coiling vs 8% clipping) and more

dis-ability in the surgical treated patients (21%

clipping vs 15% coiled).125 Rebleeding rates were

substantial— and unacceptable for some critics—

with 2.9% for coiling and 0.9% for surgery

A sta-tistical model using the ISAT data also projected

that the lifetime rebleeding rate may be

unaccept-ably high in young patients (< 40 years).121 Better

coiling techniques and less “redos” may change

these projections

Recurrence of SAH after satisfactory tion of the aneurysm by surgical clipping is low

oblitera-In a large study from Japan with a median follow-

up of 11 years, recurrence approximated 3% The

risk of regrowth of a previously clipped aneurysm

was 0.26% annually De novo formation of

aneu-rysms after clipping was 0.89% annually and, as

expected, was more common in patients with

prior multiple aneurysms

C O N C L U S I O N S

• Basic management in SAH consists of (a) endotracheal intubation if patients cannot protect their airway, have aspirated,

or have acquired neurogenic pulmonary edema; (b) adequate fluid management with

2 or 3 L of 0.9% sodium chloride; (c) no antihypertensive agents unless mean arterial

pressure is more than 120 mm Hg or 160 mm

Hg systolic; (d) nimodipine, 60 mg every

4 hours; and (e) pneumatic compression devices and pain management with codeine

• The management of rebleeding consists

of mechanical ventilation, antiepileptic agents if seizures occurred and emergency angiography on recovery, and early clipping

or coiling

• Delayed cerebral ischemia is managed

by hemodynamic augmentation and, if this is unsuccessful, angioplasty or intra- arterial administration of verapamil or nicardipine

• Ventriculostomy is indicated in acute hydrocephalus and hemoventricles

• Lumbar drain placement may decrease subarachnoid blood and control ICP

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Ganglionic and Lobar Hemorrhages

By and large, intracerebral hematomas are

caused by a ruptured penetrating arterial branch damaged by the effects of longstand-

ing hypertension This rupture may thus result

in hemorrhages in the caudate nucleus,

puta-men, thalamus, cerebellum, or pons Hematomas

involving the subcortical white matter and cortex

may have different causes, including vascular

mal-formations This fundamental distinction is

clini-cally relevant because cerebral angiography may

be urgently indicated in a lobar hematoma and

may be of less importance in ganglionic

hemor-rhages in patients with known poorly controlled

hypertension

Ganglionic and lobar hemorrhages account for a considerable proportion of admissions to the

neurosciences intensive care unit (NICU) Each

type of cerebral hematoma has different

charac-teristics, and they may be related to the risk of

deterioration Patients with expanding lobar

hem-orrhages with mass effect may be sent directly to

the operating room In most other patients,

medi-cal management is preferred and touches on nearly

all aspects of critical care neurology.28,66,100,105

In the first hours, urgent treatment decisions may include management of uncontrolled hyper-

tension and coagulopathy These hemorrhages

have the potential to enlarge in at least one- third

of patients;15 therefore, virtually every patient with

a putaminal or lobar hemorrhage needs close

clin-ical monitoring in the NICU

C L I N I C A L R E C O G N I T I O N

Location of the hemorrhage typically is in the

putamen or caudate nucleus The cause is a

rup-tured lateral branch of the lenticulostriate artery

Equally common are hematomas in the thalamus

from ruptured thalamoperforating arteries Some

of these hemorrhages are apoplectic, creating

large, destructive volumes with extension into the

ventricular system.67

The clinical hallmark of a spontaneous bral hemorrhage is rapid unfolding of a focal neu-

cere-rologic deficit and then fluctuating alertness The

neurologic manifestations of intra- cranial toma depend on the location of the hematoma.Hemorrhages may be superficially in the sub-cortical white matter Patients with frontal lobe hematoma are markedly disoriented in time and

hema-place, and many are abulic (from the Greek

abu-lia, indecision).34 Patients with abulia become diverted when asked to perform a simple task or

to recall a recent major event in the world They lack any initiative and truncate their conversation with a simple “yes,” “no,” or “I don’t know,” and even these answers require a disproportionately long time

Patients with hematomas in the dominant (left for right- handed) parietal lobe display abnor-malities in naming, reading, writing, calculations, finger identification, and left– right distinction

In contrast, patients with hematomas in the dominant (right for right- handed) parietal lobe largely experience neglect of the opposite body half Neglect of a hemiparesis may be associated with difficulty with writing, particularly omission

non-of letters Occipital hematomas may be fested by visual hallucinations and bright colors, but homonymous hemianopia often remains the sole clinical finding on examination

mani-Seizures (mostly focal) have been reported, with an incidence of approximately 30% in lobar hemorrhages but a much lower incidence (5%) in ganglionic hemorrhages that spare the cortex.122

Seizures occur close to the presentation of rhage, and late- onset seizures are less common.11,68

hemor-Deep- seated hemorrhages involve the striatum— divided into the putamen and the caudate nucleus— or thalamus The clinical syn-dromes in patients with hemorrhages in the puta-men have been further divided on the basis of whether the lesion affects only the anterior part

of the putamen close to the anterior limb of the internal capsule, the middle part, or the poste-rior part Hemorrhage localized to the anterior part of the putamen may produce purely motor hemiparesis, eye deviation to the site of the lesion, and abulia Extension into the middle part of the

Part VII: Management of Specific Disorders

348

putamen may additionally result in spatial neglect

and decreased sensation evidenced by

dimin-ished awareness of pinprick, touch, and position

Extension of the clot into the posterior putamen

leads to a more prominent left- sided neglect in

right- sided lesions and fluent aphasia in left- sided

lesions Large hemorrhages in the putamen may

dissect along the white matter tracts into the

tem-poral lobe, causing a Wernicke- type aphasia, but

periclot edema may also impair the function of

the temporal lobe

The neurologic deficit in a putaminal

hem-orrhage is commonly stable when the patient is

admitted to the NICU However, neurologic

defi-cits may become more pronounced, signaled by

stupor instead of drowsiness or by development of

a forced gaze.19 Progression of neurologic

symp-toms, indicating enlargement of the hematoma

with more mass effect, is commonly noted

clini-cally within the first 6 hours after presentation

Hemorrhages in the thalamus produce eye

movement abnormalities, such as downward gaze,

skew deviation, and limited abduction of both

eyes, simulating a sixth- nerve palsy.72 Hemiparesis

occurs with paramedian extension The pattern of

anosognosia and visual spatial neglect in the

non-dominant thalamus and aphasia in the non-dominant

thalamus holds This type of aphasia is notable for

mutism evolving into verbose jargon speech with

relatively retained understanding and repetition

In patients who have extension of the thalamic

hemorrhage into the striatum, verbal output may

be less pronounced, and hypophonia and

dys-arthria may predominate.70 Sentences offered

for repetition are at times restated in a different

manner

Caudate hemorrhage is the least common of

the classic hypertensive hemorrhages, and its

clin-ical manifestations often can be inferred mainly

from an extension to the ventricular system

Mostly patients are disoriented and confused,

followed by a decline in consciousness from

dif-fusely enlarged hemoventricles.113,120 When the

hematoma enlarges and extends from the

cau-date nucleus into the white matter, involving the

internal capsule or putamen, level of

conscious-ness decreases because of brain shift Extension

of the hemorrhage into the hypothalamus and

diencephalon might produce complete Horner’s

syndrome on one side, a diagnostic clue to a large

extending caudate hematoma

As a rule, consciousness is impaired in lobar

and putaminal hemorrhages when there is mass

effect from the hematoma Therefore, enlargement

of the hematoma must be suspected in patients who lapse into deeper stages of coma In these situations, it is not uncommon to find a major dis-crepancy between clinical examination and initial computed tomography (CT) scan Repeat CT scan often uncovers considerable enlargement com-mensurate with clinical findings

Putaminal hemorrhages (more than 60 cm3

on CT scan) may disconnect the diencephalon from the ascending reticular activating system by direct destruction, and this is the most common mechanism for coma Any other large- volume hemorrhage may produce mass effect, displac-ing the thalamus and upper brainstem (Chapter 12) and may additionally compress the foramen

of Monro.123 This ventricular obstruction results

in acute ventricular enlargement of the ventricles opposite to the hemorrhage However, impaired consciousness in this clinical scenario is a clini-cal manifestation of tissue displacement104 or destruction, and not acute hydrocephalus An acutely placed ventriculostomy, therefore, does not improve the level of consciousness in this par-ticular situation

Primary intraventricular hemorrhage may be caused by arteriovenous malformations in the proximity of the ventricular system, intraven-tricular tumors, and use of thrombolytic agents Uncommon causes are coagulopathy in patients with severe thrombocytopenia associated with a hematologic malignancy and moyamoya disease from rupture of the dilated periventricular arter-ies.93 It may be difficult clinically and by CT scan criteria to differentiate spontaneous intraventric-ular hemorrhage from a small thalamic or caudate nucleus hemorrhage when there is overwhelm-ing filling of the lateral portion of the ventricles Intraventricular hemorrhage is also caused by a rupture of the anterior communicating aneurysm, which can dissect through the lamina termina-lis to enter the third ventricle and connecting ventricles

Primary intraventricular hemorrhage has a clinical presentation similar to that of aneurysmal subarachnoid hemorrhage Although less severe presentations may occur, onset is acute, with immediate loss of consciousness and often spon-taneous extensor posturing.93 Many patients have rapid breathing with periods of apnea or barely audible air displacement and need to be immedi-ately intubated and placed on a mechanical ven-tilator Increased blood pressure most likely is a consequence of transmitted intracranial pressure affecting the brainstem, particularly at the rush

Chapter 27: Ganglionic and Lobar Hemorrhages 349

of arterial blood through the ventricular system

Pupil reflexes may become sluggish and pupil

size smaller if acute hydrocephalus develops

rap-idly Any change in this direction should prompt

a repeat CT scan to evaluate the progression of

ventricular enlargement and need for

ventriculos-tomy and thrombolytics

N E U R O I M AG I N G A N D

L A B O R AT O RY   T E S T S

CT scanning provides the opportunity for

care-ful characterization of the parenchymal

hemor-rhage, and some measurements have clinical

implication The volume in cubic centimeters can

be measured on CT scan by the ellipsoid ABC

method:14 [A × B × C]/ 2 (Figure 27.1) (A is the

maximum diameter, B is the diameter

perpendic-ular to A, and C is the number of slices in vertical

plane with hematoma present multiplied by slice

thickness in cm [usually 0.5 cm]) This

approxi-mation of hemorrhagic volume assumes that

every hematoma is ellipsoidal Overestimation

(by as much as 30%) may occur when hematoma

is irregularly shaped or separated in pieces.121

However, mostly the value obtained correlates

well with a direct CT scan measurement

In 25% of patients, enlargement of the glionic hematoma may appear on CT scans when

gan-reimaged within the first hours of presentation

Patients with CT scans obtained more than 6 hours

after the ictus and a volume of less than 25 cm3

are unlikely to have deterioration from further

growth of the hematoma However,

anticoagula-tion with warfarin, despite rapid normalizaanticoagula-tion

of the international normalized ratio (INR), is a

major factor in enlargement of the hematoma

Putaminal hemorrhages are most lent and not infrequently massive The volume

preva-on CT scan commpreva-only approaches 60  cm3, but

smaller hematomas may occur without further

enlargement on serial CT scans Types of inal hemorrhage with common pathway of exten-sion are shown in Figure 27.2

putam-Thalamic hematomas are usually small (Figure 27.3); but because of close proximity to the ven-tricles, intraventricular hemorrhage may occur Hydrocephalus may develop from obstruction of the cerebrospinal fluid (CSF) at the level of the foramen of Monro (Figure 27.4), more commonly with medially located thalamic hemorrhages Enlargement of the hematoma has been observed

in thalamic hemorrhages, typically in tion with progression to coma The progression is destruction not only of the thalamus but also the mesencephalon, and this combination markedly reduces the chances of independent living The

conjunc-CT scan and magnetic resonance imaging (MRI) features producing coma in patients with thalamic hematomas are shown in Figure 27.5

Caudate hemorrhage (Figure 27.6) may be difficult to separate from intraventricular hemor-rhage on CT scans, and often MRI is needed to locate the source in the caudate nucleus

Lobar hematomas are peripheral and just under the cortex Patients with lobar hematomas may have an underlying arteriovenous malforma-tion or cavernous angioma Simultaneous mul-tiple hemorrhages should point to previous use of anticoagulants or thrombolytic agents, dissemi-nated intravascular coagulation, metastatic dis-ease, or as a result of infestation with aspergillus

or toxoplasma.80,124,126,128

Several other CT scan characteristics of toma suggesting its origin should be recognized Shift of midline structures on the initial CT scan

hema-in patients with lobar hematoma is highly tive of further clinical deterioration.39 The specific features are shift of the septum pellucidum, oblit-eration of the opposite ambient cistern, and early trapping of the temporal horn (Figure 27.7) Some

predic-FIGURE 27.1: Volume of a thalamic hemorrhage as measured by the ABC method (A × B × C) In this example, A

is 5 cm, B is 3 cm, and the number of slices (C) is four (hemorrhage is visible on four computed tomographic slices

at 1 cm intervals) The total volume is calculated as 60 divided by 2, or 30 cm 3

Part VII: Management of Specific Disorders

350

of the CT scan changes may be subtle and involve

effacement of the supracerebellar cistern from

edema (Figure 27.8)

Lobar hematoma may indicate an underlying

metastatic lesion or primary brain tumor, and it is

evident by marked fingerlike white matter edema notably out of proportion to the size of the hema-toma and seldom causing brain shift (Figure 27.9).Superficially located hematomas commonly are a result of amyloid angiopathy (Capsule 27.1),

FIGURE 27.2: Putaminal hemorrhage Computed tomographic scan examples of putaminal hemorrhage (arrows)

(a) Localized (b) Extensions to capsule and frontal lobe and ventricles (c) Further extension into the thalamus.

FIGURE  27.4: Thalamic hemorrhage Computed tomographic images of enlargement of thalamic hemorrhage intraventricular extension and hydrocephalus.

FIGURE 27.5: Coma caused by thalamic hemorrhage (a) Massive extension and enlargement of ventricles (arrows)

(b) Magnetic resonance image of the thalamic hemorrhage with extension into the midbrain.

Computed tomographic images of caudate hemorrhage and intraventricular extension (arrows).

Part VII: Management of Specific Disorders

352

and MRI (preferably gradient- echo) may show

earlier hemorrhages59 (Figure 27.10)

Coagulation- associated hematomas are

commonly multiple, involving multiple

com-partments A  blood– fluid interface inside the

hematoma predicts an acquired (e.g.,

leuke-mia, idiopathic thrombocytopenic purpura,

hemophilia) or drug- related (e.g., warfarin,

heparin, thrombolytic agents) bleeding

disor-der29,126 (Figure 27.11) Hematoma shape

(regu-lar, irregu(regu-lar, or separated) does not predict

source of hemorrhage and is not more common

in warfarin- associated cerebral hematomas

Intraventricular hemorrhage can be graded using

the Graebe scale (Table 27.1)

Magnetic resonance imaging is a crucial study

in lobar hematoma because it may identify an underlying structural lesion In young adults,

an arteriovenous malformation is common; in older adults, earlier amyloid hemorrhages may

be found

Magnetic resonance imaging with magnetic resonance angiography is a useful additional test that may demonstrate metastasis, occult vascular malformations, occasional previous hemorrhages associated with amyloid angiopathy, or cerebral venous thrombosis, all conditions beyond the detection of CT Magnetic resonance imaging is able to estimate the age of the hematoma, and one

of the earliest signs is peripheral deoxygenation,

FIGURE 27.7: Computed tomographic scan signs predictive of deterioration in lobar hematoma (arrow) Note shift

of septum pellucidum and pineal gland (arrows) and early temporal horn entrapment (arrow).

FIGURE 27.8: Computed tomographic scans showing lobar hematoma (left) with some mass effect and bowing of the midline structures Several days later (right), the hematoma is resolving but edema is more pronounced, with

progressive obliteration of the supracerebellar cistern without appreciable shift of the pineal gland from edema.

Chapter 27: Ganglionic and Lobar Hemorrhages 353

shown as a rim of hypodensity on T2- weighted

spin echo images surrounding the hematoma

T1- and T2- weighted changes usually

character-ize the aging of the hematoma.7,77 Gradient- echo

MRI may demonstrate additional asymptomatic

petechial or small- volume hemorrhages of

dif-ferent ages, suggesting cerebral amyloid

angi-opathy.50 Finally, although uncommon, lobar

hematomas may in fact be hemorrhagic cerebral

infarcts associated with cerebral venous

throm-bosis (Chapter  32) Magnetic resonance

imag-ing may also document a menimag-ingioma, which

can easily be mistaken for a lobar hematoma on

CT scan.102

Cerebral angiography is warranted in most

patients with a lobar hematoma and may uncover

an arteriovenous malformation (Figure 27.12) Its

yield in a patient with normal findings on MRI

and MRA is low

The diagnostic value of cerebral angiography

for underlying vascular abnormalities has been

reviewed Many of the studies are limited because

selection criteria are unclear The yield of

arterio-venous malformations or aneurysms depends on

the site of hemorrhage, a history of hypertension

(or persistent hypertension 2 weeks after

admis-sion), and age.133

Normotensive patients with a hemorrhage in

the putamen or thalamus who are younger than

45 years may have an underlying vascular lesion

(50% occurrence) The detection rate drops to 7%

in similar patients older than 45 years.133 However,

yield from cerebral angiography in chronically

hypertensive patients with ganglionic

hemor-rhages is very low The yield in patients with

primary intraventricular hemorrhage varies from 30% to 75%

Therefore, cerebral angiography is probably not warranted in patients with a typical putaminal

or thalamic hemorrhage and long- standing tension Putaminal hemorrhages are seldom asso-ciated with cerebral aneurysms, but when present are commonly visible on CT scans or the hema-toma seems to originate from the middle cerebral artery implying an underlying aneurysm Cerebral angiogram may lead to surprising results, and we found a P3 aneurysm in a patient with predomi-nantly thalamic hematoma but also subarachnoid hemorrhage.21 Repeat angiography may be needed

hyper-as a follow- up study when cerebral angiography yields negative results in a patient with a lobar hematoma (It is possible that the mass effect of

a hematoma obscures a small arteriovenous formation Repeat angiography detected four

mal-FIGURE  27.9: Hemorrhage in metastasis Note the comparatively large, finger- like edema in the white matter out

of proportion to the size of the hematoma Computed tomographic scans mask underlying metastasis, which may be more clearly demonstrated by magnetic resonance imaging.

TABLE 27.1. GRAEBE SCALE: SYSTEM FOR GRADING SEVERITY OF IVH

Lateral Ventricles

1 = trace of blood or mild bleeding

2 = less than half of the ventricle filled with blood

3 = more than half of the ventricle filled with blood

4 = ventricle filled with blood and expanded(Each lateral ventricle is scored separately)

Third and Fourth Ventricles

1 = blood present, ventricle size normal

2 = ventricle filled with blood and expanded

Total Score (maximum = 12)

CAPSULE 27.1 CEREBRAL AMYLOID ANGIOPATHY AND CEREBRAL

HEMORRHAGE

Aging causes deposition of amyloid- β protein in blood vessels— mostly in the cortical and tal regions— and compromises arterial wall integrity 49,111 This process goes by the moniker of

occipi-cerebral amyloid angiopathy.

It has been estimated that amyloid deposits are present in the vast majority of nonagenarians, but the lower cutoff age is unknown and may reach into the mid- 40s Their deposition may be due to reduced extracellular spaces that reduce drainage of these proteins and lead to deposition (Familial forms have been described, most prominently in Dutch, Danish, and British families.) Fibrinoid necrosis is seen, and may be a possible mechanism of rupture The same mecha- nism of fibrinoid necrosis applies to hypertension- associated hemorrhages, and to make it more perplexing, long- standing hypertension may coexist with amyloid angiopathy However, cerebral amyloid angiopathy typically spares the penetrating branches to the basal ganglia, thalamus, and brainstem Amyloid may also impact on endothelial function and fail to inhibit plasmin and plas- minogen activators, resulting in a hematoma with characteristics virtually similar to warfarin- associated hematomas (lobulated, fluid plasma levels) Cerebral hemorrhage after thrombolytic agents and anticoagulation may be linked to severe cerebral amyloid angiopathy, but the relation- ship is tentative 112 Autopsy or careful evaluation of evacuated clot and brain tissue is needed to confirm the diagnosis Neuropathologic studies require special staining methods (e.g., Congo red), but immunostaining of the protein is more specific (see accompanying illustration).

β- Amyloid staining showing marked deposits as seen in cerebral amyloid angiopathy.