A B C Head CT SAH IC P > 20 mm H g ICP < 20 mm H g Supportive care CT angiogram vs conventional angiogram and NICU management NICU: treatment of vasospasm (medical, endovascular), ICP management, treatment of medical complications • Intraparenchymal hematoma • Hydrocephalus • Ventricular hematoma Neurologic deterioration Urgent surgery Intraoperative angiogram Ventriculostomy Neurologically stable or improving Surgery Endovascular therapy p m Figure 5-133. Algorithm for the manage- ment of patients with higher Hunt and Hess grades (3 through 5). The initial work-up and management for patients with higher clinical grades is similar, but often these patients require more inva- sive cerebral monitoring, in particular with a ventriculostomy. This serves two purposes: accurate monitoring of the intracranial pressure (ICP) and drainage of cerebrospinal ﬂuid in order to relieve hydrocephalus. Even patients with coma (Hunt and Hess grade 5) may improve sig- nificantly after the placement of a ventric- ulostomy. Only patients with extremely poor examinations and refractory highly elevated ICP are not treated aggressively. All others should be considered for early treatment of the aneurysm, either surgi- cally or endovascularly, as soon as they are clinically stable. Patients with higher clinical grades are at higher risk for cere- bral vasospasm and should be monitored closely in the neuroscience intensive care unit (NICU) with daily transcranial Doppler examinations. Traditionally, the outcome for patients with Hunt and Hess grade 4 or 5 subarachnoid hemor- rhage (SAH) has been much worse, but more recently there have been reports of surprisingly good neurologic outcomes in some patients with higher-grade aneu- rysms [ 214 ]. Other factors to consider in the prognosis include patient age and medical comorbidities.
Cerebrovascular Disease 199 Figure 5-134. Poor-grade aneurysm (Hunt and Hess grade 4). A 61-year-old woman presented after being found unresponsive at her workplace. Work- up revealed a Hunt and Hess grade 5 subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm. A, Noncontrast head CT shows a large aneurysm with adjacent clot along its right wall, intraventricular blood, and hydrocephalus. B, CT angio- gram reconstruction, superior view, shows a 2.1-cm saccular aneurysm of the anterior communicating artery and an absent right A 1 . This view also shows a small outpouching on the right wall of the aneurysm, representing the point of rupture. C, Conventional angiogram, lateral view, of left internal carotid artery injection showing the aneurysm prior to coil treatment. D, Conventional angio- gram, lateral view, showing successful coil treatment of the aneurysm with 22 platinum-based coils. B A D C A B C D Figure 5-135. Unruptured aneurysm.
- Fall '19
- The American, Atherosclerosis, Internal carotid artery, Arteries of the head and neck, Anterior cerebral artery, Circle of Willis