Diapositiva 1

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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH (Grade IV and V)
Prof . Dr. Leónidas M.
Quintana Department of
Neurosurgery School of Medicine
Valparaíso University -
Chile
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
Treated Ruptured Cerebral Aneurysms ()
1990-2009 Total 929
cases
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
IV V
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
CT Scan at admission...... It makes
the difference between the posterior

management ( explained in the next slide)

and prognosis
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2
Pattern 1- Critical brain damage 2- Brain
swelling and/or edema 3- Acute Hydrocephalus 4-
Intracerebral Hematoma
3
4
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH

• Initial Medical Treatment
• 1-ABC Control blood gases- If GCSlt 8
  Intubation
• Controlled ventilation- avoid
  hypoxemia
• CPP Management avoid hypotension
  (unclipped 120-150mmHg.
• Systolic blood pressure) adecuate Central
  Venous Pressure (6-12 cm H2O)
• 2-Sedation Analgesics- if intubated muscle
  relaxants
• 3-Nimodipine 60mg q.4 hrs per NGT
• 4-Phenytoin 1gr initial 100 mg q.8hrs per NGT
• If GCS lt 8 ICP Monitoring EVD or Spiegelberg
  system
• 
  HSS
• ICP monitoring 2
  Manitol
• Comfort measures
  Hyperventilation
• 
  Surgery
• 3 EVD
  4 as soon as possible

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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
TOTAL 214 CASES IN
POOR SAH GRADE After the anterior management
( slide 5)- Re-evaluation at 12-24 hours
No improvement 75 cases Clinical
improvement 139 cases
(35)
( 65) Comfort
measures Angiography
DIED
DIRECT SURGERY
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TOTAL 214 CASES IN POOR SAH GRADE
IMPROVED 139 patients Grade IV
114 patients ( 82) Grade V
25 patients ( 18) NOT
IMPROVED 75 patients() Grade IV
16 patients ( 21 ) Grade V
59 patients ( 79 ) ()The majority
of these patients had pattern 1 and 2 at the
initial CT Scan
Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
TIMING OF DIRECT OPERATION 139 PATIENTS
WITH CLIPPED ANEURYSMS Before 48 hours
68 patients ( 49) Between 48-72 hours
49 patients (35) After 72 hours
22 patients (16)
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TIMING OF SURGERY
Left ICA- Ant choroidal An
lt24 hours Op.
96 hours Op.
Right MCA An
Compare brain edema.. no or
slight..mild to severe
parenchymal fragility no..yes
blood-hardness of clots easy to
aspirate...difficult to aspirate
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
6 months follow up of 139 clipped aneurysms
cases FUNCTIONAL STATE State I return to
normal life State II return to life with mild
limitations State III return to life with severe
limitations or vegetative state State IV dead
114 patients Grade IV
Global results State I 41 patients (
36) State II 24 patients ( 21)
Good 57 State III 17 patients (
15) State IV 32 patients ( 28) Bad
43 25 patients Grade V State I 6
patients ( 24 ) State II 4 patients ( 16
) Good 40 State III 7 patients
( 28 ) State IV 8 patients ( 32 )
Bad 60
Total Mortality of Poor Grade SAH (n 214
cases) 53,7
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH

• Some considerations.........
• This paper shows that early and aggresive
  management , medical surgical treatment, is
  better than late management, in poor grade SAH
  ( 53,7 vs. 90 mortality)
• Early management courses until 48 hours after
  initial bleeding.
• After that period is late management.
• Not all grade IVV patients have the same damage
  pattern
• Not all cases fall in the same bag, as you can
  see in these images.....

Critical brain damage Brain swelling
Acute Hydrocephalus Intracerebral
Hematoma
and/or edema
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Management of Ruptured Cerebral Aneurysms- SAH
Grade IV and V Some considerations , that can aid
to improve complications.........
MCA aneurysm short M1 bifurcation- Topical
action of Nimodipine
Vasospasm
Pre topical application
Post topical
application
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Management of Ruptured Cerebral Aneurysms with
Poor Grade SAH
Some considerations , that can aid to improve
complications.........
Vasospasm
Marked reduction of cerebral vasospasm with
lumbar drainage of cerebrospinal fluid after
subarachnoid hemorrhage Paul Klimo Jr, John R.
W. Kestle, Joel D. Mac Donald, Richard H.
Schmidt. Department of Neurosurgery, University
of Utah, Salt Lake City, Utah (J Neurosurg
100215224, 2004) WE APPLY THE SAME CONCEPT
WITH ON LAY SUBARACHNOID DRAINAGE
The V ventricle
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Aneurysmal Subarachnoid Hemorrhage Management of
Complications Hydrocephalus 1-Acute
Hydrocephalus ( Obstructive ) , should be treated
with External Ventricular Drainage, in cases of
progressive neurological deterioration.We should
avoid complications as rebleeding and infections
(dripping reservoir over 20mmHg from 0
point) 2-Chronic Hydrocephalus (Communicating),
should be prevented with Fenestration of
LaminaTerminalis, to decrease the shunting
rate,the incidence of vasospasm and to have a
better clinical outcome . If it fails.. VP shunt
Pre Op. 6hrs Post Op.
FENESTRATION OF THE LAMINA TERMINALIS AS
A VALUABLE ADJUNCT IN ANEURYSM SURGERY Norberto
Andaluz, Mario Zuccarello The Neuroscience
Institute,Department of Neurosurgery,University
of Cincinnati College of Medicine (Neurosurgery
551050-1059, 2004)
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THANK YOU VERY MUCH !!!

Prof . Dr. Leonidas M. Quintana

Department of Neurosurgery School of
Medicine
Valparaíso
University - Chile