Webinar Topic: SAH - Sub Arachnoid Haemorrhage | Yashoda Hospitals Hyderabad

yeah good evening friends uh welcome to Tuesday's master class uh from Department of critical care medicine and they show the hospitals

hospitals in association with issm Hyderabad chapter this is most sought after because across students looking at this because senior seasoned examiners are involved for the topics of

discussion so today we have uh two senior seasoned examiners Dr sarosiser Who is out of the Department of critical medicine and virinji hospitals so he's

with us today good evening sir yeah good evening and Dr Ramesh is the head of the Department of critical medicine from

Continental hospitals Hyderabad so today's topic of discussion is I think uh most of the uh day in day out we will be seeing as a critical Physicians and

topic of discussion across all examinations including idccm and FNB and Dr and right now so basically uh for this discussion we are having two

students with us Dr srikanth and Dr Shilpa both are drmb critical care medicine students from the hospital so um Dr Shilpa will be presenting the

case so it helper you are good to go yeah please start the case thank you good evening the discussion is now

can you please next slide please yes 33 year old female patient came to the hospital with the complaints of

headaches that is since two days which was diffuse in nature and it was not subsided with medication and then the vomitings of around two

episodes containing food food particles since uh one day and then she had a Caesar like activity which is like stiffening of the hands dueling of the

saliva associated with sunlight and excuse me this is thank you foreign she has one episode like this and which

was lasted for about one minute and followed by loss of consciousness which lasted for about five minutes and uh on brief history uh there was no Caesar

disorder previously and there was no history of fever cold or neck pain or there was no ear pain or ear discharge and there is no history of trauma there

is there's no history of drug intake next slide coming to the past history there are no similar complaints in the past and she's a known hypothyroidism case that is

since five years and for which she was taking thyroxine tablet 25 micrograms per week for personal history um is insignificant with the two children and last child being around six

years of age and a family history nothing significant foreign BP is around 130 by 70 with a heart rate of 90 beats per minute there are no

moments um DC is around she's drowsy but arousable and the obeying commands um pupils bilaterally 3mm equal and

reacting to light she's moving all four Limbs and there are no focal deficits next is like temperature is 99 coming to the vitals

temperature is 99 degree Fahrenheit and her blood glucose levels is around 29 kg per meter square or ABG is

um I know at this point of time my provisional diagnosis is would be a hemorrhagic stroke or it could be uh

several sinus Venous Thrombosis or could be a meningitis or migraine or any space occupying relation okay so now um based on the history

these are all your differential diagnosis uh suppose if you think that it is a case of csvt so what are the histories you want to take in terms of like personal history or any other drug

history specifically you want to ask the things she is in their predictive age group she might be on a oral contrast tips in a recent change in the drugs or a current intake this history

we have to take it okay so uh thinking in terms of motor examination you uh have you example for Canon level examination

she's drowsy Cooperative to examine cranial loss so if you think that it is RNA crane nose which is involved

specifically in this case um sixth training loss are mostly due to raised intracranial Treasures are most commonly inward cell

um but in this case the pupils being normal so we did not suspect raised endocrineal pressure and uh there were no lateralizing signs

suppose if she presents with the ptosis or something like that like what crayon love is involved or what what is the mechanism of that in case of suburban hemorrhage [Music]

yes okay oh this especially [Music] um if you're communicating aneurysms can

involve the brainstem involvement can involve the third candles you can suspect in these cases okay so any importance of family history

in this case if any family members had a similar history of intratinal hemorrhage or

Caesar then we must because some familiar disorders can also associated with of this vascular Mall formations

so looking at your provisional diagnosis any like fundoscopy will help in which all conditions in this case in in all these differential diagnosis will help us

um if to do any uh like papilledema features to look for uh toxic toxic encephalopathy we can roll up at the same time

um like due to hypertension disorders or maybe due to um raised intravenal pressures due to any

space occupying Leisure or due to meningitis itself and yeah csvt will have like a significant amount of venous we can easily make out

in a fundoscopy examination even in case of sh also if there is a rise in fragrant pressure we can make out with the papillating operations of class

peptidime okay so go back to your history slides okay suppose if she has a history of headache prior to this

um like is that a warning sign for you yes it can be so it can be a sentinel headache um it may be a there may be small doctor might have happened by spontaneous

closure again before the again event it can indicate that the central event might have happened earlier okay so Sentinel bleed okay so what is whatever scale

Hemorrhage in your case what are the symptoms which will tell us that this patient has a high suspicion of uh subordinar bleed

the headache which is severe in nature most commonly described as standard cap headache and which was abrupt and then

associated with nausea vomiting and season activity is most commonly associated with due to irritation of the entertainment messages and Rapid change

in the sensory um so any deficit next stiffness not able to flex the neck all these things will come in that no which has high suspicion which will rise high suspicion

towards sh you know okay basically this nature of the headache is very very important so as you told me it's your description for headache also you need to describe

whether it is a continuous headache or intermittent headache that is also and the severity and maximum headache reaching within one hour that is also very important for a

class this Thunderclap headache as you told so it's maximum that is also it is a part of the your whatever scale means so different

parameters are there so from that parameters you can come to have that yes person is having high suspicion for a

summer at night Hemorrhage so you can go for a different Industries after that neurological examination detail when you are presenting an illogical case

detailed examination is important because either a motor examination cranial lumps examination level of sensory on GCS all these things detail

like germination is necessary so in the neurological examination what are your positive findings are you posting uh finding sir

at this point of time she doesn't have any positive she's drowsy so my confusion was there otherwise she was obeying and

oriented to time place person and there are no focal deficits at that point of time so no next stiffness non-acrigidity or no neck pain nothing

she was continuously complaining of only headache I'd like to complain was that but neurological science nothing was no significance

so what is your provisional diagnosis first provisional diagnosis how you think of yeah it could be like infra training

Hemorrhage or it could be a csvtc which comes first in my mind but like considering the age and the ruling of the infection first and the other

intoxication space occupation sorry intracranial hemorrhage where you are thinking

um like um I mean to say sabarign due to spontaneous or aneurysmal ruptures due to the presentation like a headache

and this vomitings and seizure which was certainly not set and then involving uh the sensor decreasing the sensorium but she doesn't have any

infection related history the blood pressure was a normal yes blood pressure was a normal no yes so we look fine in hemorrhagic Strokes

blood pressure normal blood pressures usually we find either the history of history on Earth and

with high blood pressure at the time of initial examination in hypertensive and the level of sensorium and neurological deficits usually if any

person is having a bleeding entrepreneurial bleed foreign so neurological manifestation might be

significant at the time of admission okay why you asked for year discharge ear pain and all

right to rule out any uh 4K of infection uh to cause meningitis um medication what medications you are having in mind

uh like um if she has any if she is on any medication any overdose of any pills

like suicidal tendency also since she's in female so we tend to ask Maybe any any medications which will cause seizures and headache

if taken in overdose so in the examination you told about blood pressure no is there any importance for uh like upper limit lower volume blood pressure separately in this case

in iotic dissections there can be differential prices in the upper Limbs and lower limbs to this

so will that present as a headache a neck pain center okay coocation of Iota will be associated with some moment of an original bleed and all so that's why

Upper Limb and rolling BP is recorded and differentiation of the top element should be appreciated and any importance of murmurs in this case in your written

no no no murmurs had if there is a murmur what you'll suspect any regurgitant religion uh any thrombotic phenomena we should suspect

we might be having some valve replacement or underlying a heart diseaser you might be on some anti-platelets or antipogly interactions which may can cause uh some intracranial

bleed that can be give a clue very good very good so based on that uh if the patient is having some more marvelous can prone for input to endocardial cells so that can also cause some mycotic

aneurysms causing bleed in the brain okay so disability why this like motor examination uh based on this what information will get

like this year scoring at what point of time you have to take Airways paid in Utah no no secretions no Expressions what point of time where you have to

intubate the patient in any CS CNS case if a patient GCS is less than eight and she's unable to protect her Airways or

in case uh like abnormal breaking pattern uh associated with low GCS and if associated with the hemodynamic

instability and if it is post a season if she's maintaining the airway potency or not because they will be imposter confusion

uh so we first look for the airway potencies equation she would not be able to maintain the airway might lead to

aspiration so suppose if you consider this as a Suburban Hemorrhage what is the importance of family history I asked this previously also is there any

conditions which will come in families with aneurysms diseases um collagen this is associated collagen

disorders they are more prone for any reason for machines syndrome uh pseudos Anthem uh all those things and usually familial will have multiple aneurysms in them right you

know and even sometimes polycystic kidney disease or sometimesis here next slide what is Central fever temperature is 99 eurater

since it is a CNS case you should know about Central fever until fever it is a mainly the diagnosis of extinctions all the common causes of fever in the

ICU whether it is new onset or the patient is admitting with the fever after rolling out and then if there is an illusion that is involving the hypothalamus then we can contribute the

fever to Central origin okay so you mentioned lactate as 4.6 what would be the reason for that um here we are thinking that um it might

be due to um procedure activity which was generalized only clonic energy so we thought it could be due to that or we should rule out since she has a high

grbase we should also do not urine ketones which was performed to be negative activity next so the basic investigations which we

send are a complete that picture and the population profile and uh leave a function test and renal functional test in the randomly fructose and HP A1C cmts

and she was um first we have taken her to a non-contract CT brain after taking out the blood samples and then um

after coming to the icos plant next slide but today easy suggest ECG suggestion of 10 versions

being positive and um revealed there was a regional original wall motion abnormality with the moderate LV dysfunction with the

ejection fraction of 40 percent um that's it these were the positive findings the ECG and uh

next next Hemorrhage and uh which was minimal ivh um in a bilateral occipital hands acute ischemic changes and ruptured aneurysm

uh the there was a absolute even segment in the right ACM we are presenting the investigations now first we will come with the basic investigations like blood tests

and then we'll go to the basic non-contrast plain CT scan and then to the MRI now um sit um initially we have taken a CT

cell which was normal uh like we did not find a significant uh significant changes so we uh and then there was a

then the history of headache was since two days so we thought uh growing an MRI will help us um uh in this case because uh if CT is

very good in case of uh like subaric not Hemorrhage if we are suspecting in the initial 12 hours the sensitivity is 95 to 100 but if it is 24 hours again the sensitivity comes down to 93 and again

after five to six days the sensitivity goes down to 63 so um then we we also suspected uh for her

csvt uh so we and also wanted to rule out the meningitis so we thought of going ahead with MRI so we went here with the MRI with the angiograms okay so

you but that is an event for MRI yes yes what are the conditions wherein false negative CT scan will be there in

hemorrhages uh yes the presentation is late so usually after 24 hours the sensitivity goes down

so it will be difficult and also paying reasons usually we will not find in CT scans no

yeah if there is a small bleed or if the hematocrit of the patient is very less even then it can be missed as with all it can be if it is prolonged if it is

delayed presentation also uh suppose if it is delayed presentation what is the next investigation which is preferred if she's having a headache um angiogram

no the thing is the question is clear what he is asking is if your delayed presentation and your initial city is normal yes you have a high suspicion you have a

high degree of Suspicion for us about retina Hemorrhage what you should do so how to confirm your diagnosis of uh there is a xanthrombia due to break down

of the rbcs so that could be done but nowadays really we do it because we go ahead with uh with GRE and player sequences can give

an information of the uh presented to you within six hours and the patient you have a high suspicion but City you have done in the city it is normal no subordinate

Hemorrhage but you have a clinical science of sovereign CSF analysis uh no sir within six services at least you need to wait for how many

hours to do CSF if you want to do install just not before 24 hours before us we should not do at least you need to

wait for 12 hours to look for gentapuram suppose you want to take a decent by doing a CSF analysis look for xantho chromia so at least you need to wait for 12 hours

and MRI is when is the ideal time to go for MRI suspecting a clinical suspicion for a subarachment hemorrhage your city

supports cities in Norman you but you have still have a strong suspicion you have not done the CSF analysis

uh after six six to 12 hours after the presentation so usually a marriage changes will not develop initially so you need to what

type of images in MRI sequences you need to see the GRE sequence is very inflation yes

so if you do at least after 24 to 48 hours if you do the America pictures will be clear Clarity and and your look for the early sequences for your

diagnosis thank you yeah yeah please get it sorry for your introductions you can continue sir yeah

anything uh for a city uh City NGO any indication for a city NGO in this case so in high index of Suspicion with the

initial uh CT scan non-contest cities not resist of anybody then uh we can go for City cerebral angiography so it can give the vasculature picture as well as

a PC purchase a patient territory also can be clearly visualized thank you and the city per Fusion scan

indication for any City for pigeons can is necessary in this case if it is we don't usually will see so unless it means usually not indicated

for us to go for a city perfusion scan so City NGO cerebral and you will go but if you have any Associated condition

things like Associated means Associated ischemic stroke then in that case you go for the city and you so that will helpful for a r

present later part of your in the suppose after time is delayed already three days four days happen this patient already two days but you have a string

suspicion for a uh and your expecting some complications than that time you can go for a City

Engine a city in City perfusion scan along with the city and you know so grossly if the patient presents with you with no neurological deficits stable

patient if he is presenting with less than six hours then CT scan is recommended if it is negative then we can treat us other uh causes of headache or migraine all those things

and all you know looking at the like physical work up all those things we have to do if the patient travels with you with some scissors or neurological deficit of more than six hours then if

the city is negative then plan for LP CSF analysis if you look for the xanthotroconomics test with spectral spectroscopic analysis in that and uh if so usually

these two will pick up almost the sensitivity of those two will be very high the city is negative it will be picked up by the CSF analysis

MRI usually very rarely we do and um so yeah go on and another investigation you have done silica uh

uh second uh the previous slide can change the previous slide yeah in the ICT you have seen that t inversions in Lead 1 and AVL and with

right bundle plus pattern so is it normal or abnormal finding or whatever what is relevance to this patient

and in the tooth also you got that ejection friction was around 40 percent lvr diploma present with moderate lb dysfunction

can happen this will have effect causing effect on the contactability and chronotropic and erotropic effect which

at later stages can present as a remix of acute coronary syndromes are in the form of leechingness in in different leads T

inversions activity prolongations or some block pattern and here the topic positivity can be attributed to the catechism

or the heart and because of sudden sympathetic Surge and catacolumance at a causing stress cardiomyopathy to the heart causing

Regional I mean LV dysfunction in this patient [Music] depression and you may see different blocks

so this type of PC changes you may see in seborrheic yes so but and person may not be having a underlying coronary artery disease yes

yes so whether really patient is having underlying coronary disease our only percentage is from the ECG can you differentiate in an

acute coronary artery disease coronary artery with the subarachment Hemorrhage disease changes how will the difference it is it changes from the true

coronary changes uh if it is a I mean there should be an ST depression or St elevations based upon the uh whether it's a instamere and

on stemi and prior Q wave changes can indicate along with that if it is an chronic changes there will be definitely a P wave changes will be there if they're increasing the Heritage width of

the p waves so this can indicate whether it is an acute event or appearing in a previously with some underlying heart disease

it is sometimes difficult to differentiate from a acute coronary syndrome acute uh Hemorrhage because ST depression or a TUF inversion you may be able to see in

both conditions but how to differentiate because of the most common finding in subharic Knight Hemorrhage you will see like Duty propagation so uh with the ST depression and tub

inversion so may be present in both finally means both the conditions but usually Kitty prolongation will be there in savaragne

Hemorrhage in in mi or a coronary event due to prolongation may be normal or it may not be prolongation may not be there

and the Deep wave changes also you have to see the pattern of TUF changes so there are some specific to your changes in subharatnam Ridge and specific tip of changes in the

MI so usually sort all means that you have in person like narrow and tinted

tall tented tea wear or narrow narrative we will see in real Mi whereas uh in sabaric Hemorrhage you may get a broader

some few changes but it's maybe difficult so unless you do a coronary NGO if you have a high suspicion for a cardiac event along with subarachment

Emirates you need to go for an NGO in that situation suppose you have a high suspicion for a corner event and percent is having some arachnid

hemorrhage antipolatelet you cannot get so how to proceed about the person suppose you have a high suspicion you

want to give antiplatelet then how to proceed about the antiplex the patient is with you you are looking at ECG and ECG are in favor of Mi along

with severeign [Music] then how to proceed about it leave the person like that no

here the it is mainly due to the catecholamide said sir so um it is not due to ischemic event that

we have to give a platelet at this point of time yeah so uh we have to initiate we have to maintain the um we have to do

the pain management properly and uh um so that her anxiety uh and uh should come down and then

um other hemodynamic support should be given uh rather than giving only the anti-platelets if if BP is going down maybe we can support with inotropes

um the um that those things you manage a part of those are on management per subaractment

damage yes along with that Hemorrhage you have some message changes which are in favor of acute Corner event so for the decision person needs an

antiplatelet so that situation how to decide about that so antiplatelet so usually you should go for again a new first stage

that whether you are keeping or going for clipping or coiling then once you do the procedure then you can start immediately antiplicate and then you can go for an

NGO or narrange you after going entrepreneur you confirm your diagnosis says whether a patient is having coronary CID is there or not yes if it is there then you can whether person

needs a standing or whether person needs only medical therapy you can decide are the supposing coronaries are normal then you can stop the interplatelet not necessary

and in your investigation list you have written EEG yes what is the role of EEG here

uh it seems uh she since she's drowsy and the history of for Caesar we don't we want to rule out any ongoing Caesar activity sir so for that reason uh we ordered um

and uh because um any further uh in a Caesar episode will worsen the situation like the risk of free bleed will be there so though we

have started on uh anti-platelet anti-epileptic therapy we want to see the um like effect of these anti uh epileptic therapy so for that reason we

are going ahead with ages um before clipping we should go ahead say before keeping we should go ahead with um

anti-epileptic cell if there are no recurrences there is no need for uh you know continuing on the anti-epileptic Therapies

before securing of the aneurysm another episode of figure kind of further because it can cause catastrophic events here in these patients uh prophylactic

figures can prophylactic anti-epileptic medication can be used uh but after uh securing of the aneurysm either by calling or the clipping uh we can do

depending on this profile we can stop the treatment but if the patient has seizures before securing of the aneurysm

we have to continue the anti-eplyptic medications in these patients and at the same time when you're assessing the severity of the person's condition your clinical severity and severity when you

are assessing for in a case of Southern Hemorrhage so in severe cases percentage is suppose more than three grade three suppose person is presenting or clinical

you are a World Federation neurosurgeon that also suppose presenting is a more than greater suppose person is presenting and unexplained unconsciousness and even after

correction of your aneurysm repair and the person is still not improving clinical in that situation you can go for an EEG

for a non-convulsive status so look for any non-convulsive status okay in good

in the delayed period after one week or after four or five days since we are discussing about e

is if there is a drop in sensorium then we should consider but if the patient is improving and then then after as I said already it is after

clipping or after securing the aneurysm then there is no need of containing the antibiotic therapies any Nuance from the

basis status so we have to exclude a seizure activity going on so in this patients the EEG need to be done yeah it can also detect the delayed

Circle you see me also in case of sh by the change of beta activity in the delayed not in the accurate presentations okay okay go on now you have this patient who has a

history of headache and then it is you have diagnosed it as a Suburban Hemorrhage based on the clinical history and the examination pattern how will you explain the attendance what is the prognosis what could be the prognosis

how is the survival rate based upon there are two problems Federation of neural sentences scale and other content is grading they divide

into two grades good grade and poor grade good grade is one two three where grade one it is a GCS of 15. uh grade

two is between uh 13 to 14 with no no motor weakness grade three is uh 13 to 14 with weakness whereas poor grade is a

grade 4 and grade 5 in grade four uh patient is having these days of 7 to 12 is aspect of four motor defense and grade 5 is this is between three to six

in respect of any motor addresses so in grade one two and three um that early uh securing of the aneurysm can have a good recovery

whereas poor grade we have to wait till there is a further Improvement to the higher grade till to be proceed with the surgery how is the survival rates in this oh

paid four and grade five and eight five mortality is more than 50 percent so in my great Fighters Royal is around uh ten percent uh but it was world

studies and in grade four it is around 20 percent uh four five six it is around 40 50 60 like that okay so grade one grade two is having

very good curve survival rates any other scaling systems you have another is hunt and his grading sir um foreign [Music] [Music] [Music]

[Music] [Music] chances okay next slide we have done a CT cerebral angiography in this patients here so in this patient

it was suggest of a the picture is showing um involvement of the hyper intake cities in the systems and BSL systems and anterior and right Sylvian creature

next slide and this is a showing uh in the inter hemispheric and the Sylvian figures

next slide so this is a cerebral angiography these are showing a wide neck sector aneurysm um arranging from the anterior

communicating water 5.5 into 5 into 5 mm and absent A1 segment uh other uh other other vasculature were under marketing

next slide based on the city can you diagnose whether it is an anterior circulation shr Post circulation sh it is an anterior circulation

which will have a high suspicion of Android saturation like when the basal systems and Sylvian figure and Inter hemispheric these are the distance when it is involved it is

the indicating of MC and ACA iterator involvement so it indicates a anterior circulation acids which is more common anterior posterior

anterior is most common in the anterior which is most common site okay anterior communicating artery is the most common site for uh this is a

friction point where the chances of development of aneurysm is very healthy okay so the junction of a com and ACN it is the most common site

in the posterior circulation which is the most common site a posterior communicating artery um okay

so here the here is amazing yeah and these are most you told in your case you got aneurysm and uh some

suppose you don't get aneurysm and uh what will be so what person is having damage what you will do now first noun any reasonable causes

stage can be we have to roll out a traumatic causes another is the AV malformations uh and there is uh any patient having

underlying the systemic disorders maybe due to a liver dysfunction or a renal dysfunction and you whether the patient is on any drugs such as anti-plated or

anticoagulants so these are the causes of non-one reasonable sh causes has to be looked into

malformation also it comes under your uh every malformation also um sometimes and this section intracranial are interceptable uh kernel

uh internal either vertebral artery or main basilar Artery Dissection sometimes it can present can have a this one those

are non-emergency causes or csvt also can person can present with this thing and Drug diffuser says okay is one of the drug addicts

yeah rampantly some because if you're young age if you are getting very young age non-hypertensive and suppose uh my 18 years 20 years boy

something going to college and comes with a subarachnid hemorrhage city is not showing an aneurysm NGO is not showing an endogen it should have a high

suspicion for a drug abuse and anyway we'll go for a other evaluation also is there any management difference between aneurysmal essays

non-original assets either traumatic acids because the presentation sh will be you need you can diagnose soon after doing a city

renewable diagnose but is there any management difference so you said like in the aneurysmal uh blade uh

like an original sh we try to like as early as possible we'll try to secure the aneurysm um because

um the chances of period are up to 30 so uh and um like risk of further versioning in these cases will be more when compared to the traumatic because

once the trauma is taken out then we should probably dealing with a cerebral edema and other complications of bleed but to hear the chances sorry bleed and

further worsening like rapid worsening is in our priorities so it differs yeah and some and the second thing is in your

case you got already energy now how will you manage this case oh is it you know initially the airway and the circulation will be taken career

and then um I'll be uh you know like taking or taking care of her pain she was complaining of severe headache for which

I was giving like a 20 micrograms of uh like fentanyl aliquettes because it was subside it was not subsiding with 650 mg of acetaminophen which was uh which was

we were giving it sixth hourly and then um uh then we have started on anti-epileptics and we even started her on injection marital as an anti edema

measure and then we try to keep you volumic and we um though we have not supplemented any Oxygen here we should not allow her to go into hypoxia because

she was drowsy and we are not alone like we are not supposed to like increase or like a low hypercapnia and any risen temperature which should be closely

monitoring because these are other all things will further worsen the ICP and now what was the indication for manital here why you have given manital

um injection marital one gram was initially given um because she was drowsy and we thought we did not do nsds at that

time and so as the edema measure we have given sevens it was the city was also not suggestive of any

any raised any signs of raised internal tension pleasure ICP except for headache and that vomitings we started on

except for that too no other signs we could found we couldn't find so that should be proper indications for uh ICP so how will you suspect that person is

having a raised ICP raised ICP uh like the symptoms we have to look for uh like Headache nausea vomiting and neck pain and uh any

vocabulary asymmetric we should look for any popular edema we should look for and onsd using ultrasound and in case of any further drop in the conscious State

Should alarm us like there is an ongoing rise in the ICP and also on ultrasound uh we can by using transcranial Doppler

where we can pulsatality index can be calculated or increase in the though on first day it is not so common so we can go ahead with measuring the

pulsatality index which is the mean Peak systolic minus in diastolic by mean flow velocity if it is more than 1.19 centimeter per second maybe we should consider that there is an a raised ICP

and we should take the measures that is one of the way and if in the city or in which we initially did if there is an Hydro cap and this features and then

patient is symptomatic maybe we should consider there is an ongoing ICT rights any indication for ICP monitoring

indication for for this case uh for this case any represent is uh there are no features of ICP so no need to monitor no need to monitors

uh what is the indication for ICP monitoring um I higher Fischer grades are grade 3 and above everything sh with incremental

extension where the chances of progression of hydro cap plus is high so in these patients uh we can go for an ICP monitoring a preferently an

intraventure Capital which can act as more diagnostic as well as therapeutic no sir I disagree with this like we have evidence like the best trip where uh

there was a comparison between the like invasive ICP monitoring versus uh and the neurological and the closed clinical manifestation where there was no

difference in the outcome so I think we can go ahead with the close monitoring and even in the severe grades with close monitoring as well as with transcranial

Doppler and onsd techniques and imaging like seek if feasible uh we could even do like do same as that of invasive neural monitor like ICP monitor

no definitely those persons who are having hydrocephalus so if it will be kind to kind of double purpose so you can definitely

damage and you can monitor the ICP both can be done if patient is having hydrocarus content has clinical creating is very

high for example four or five GCS is low you want to monitor persons say having signs of raised ICP and there is an

indication for ICP monitoring so maybe closed monitoring is required at that time so indicates suppose you are able to monitor with the

NST you are able to monitor by doing CT scans you're able to monitor clinically even though you do but still it has a role for uh in poorer

grade patients where we plan for an intervention so it can help in both therapeutic and Diagnostic and initial stages helping better progression

okay next part of management next slide no no Nest part management your your you are talking about the management of Subaru your case it is a

you told initially your pain management so you wanted to give opiates you wanted to give some uh antidema major anti-adimir measures

anything else fairly securing of aneurysm has to be planned sir since she comes in a better upgrade in grade two first year to answer that one actually

yeah so early as possible you have to go for an original repairing you want to go what type of what type of method you

want to go have planned for surgical keepings wait no um

um when we discussed um they uh they said like uh like from after discussing with neurosurgeons like uh the posterior uh

Ice Age like posterior artery involvement then they are mostly amenable for the coiling when compared to the anterior ones and again uh

considering into the advantages and disadvantages like if you go ahead with the clipping where um though it is an invasive procedure but the chance of

rebleding are less and when you compute when you consider the coiling since it is not posterior and coiling uh

though the this minimally invasive but the annual incidence of uh like reblades are more and um

so that is the disadvantage recurrence and uh in this case how you decide means the size of the um the aneurysm uh at

the end at the neck if it is a white neck one then we usually prefer to go ahead with the clipping cell so

more than one point more than one so and uh difficult morphology so and uh ruptured aneurysms so these are the and

anterior circulation in this uh we can go for keeping better than the oilings yeah the DSA finding there

oh she knows it now we have no we only done a CT Circle then after that any Next Step management suppose you have went for clipping then any anything you need to do for

management or is it like we started her on the Cardiff in uh 60 mg fourth hourly tablet for neuroprotective measure in order to

prevent the like leadership like immediately immediately we started like um like after diagnosing subarachnoid

hemorrhage we started then anything else how you want to monitor because monitor is monitoring is a part of the management so this person's severeign

foreign [Music] any other than these medical complications you have to identify and

then since she's already having a suburbating right so chances will be will be high so and immediately we have

to start on the uh any more Depend and we have to maintain the target bit figure uh to before securing of the aneurysm on a higher side to maintain

the perfusion uh once the candidism has been secured the BP targets can be reduced so and we have to maintain a uvolumix status through thermia status

and avoid hypoxia and pain and agitation has to be addressed at the same time uh she since she presented with the seizures we have to proceed with the anti-epileptic

medications yeah the scientific you want to do you want to give here we have started

answer one gram initially was given and then 500 MGB device tablets why not funny time

is associated with hypotension so more comfortable because here we try to avoid hypertension we want to maintain even before clipping maybe it is okay

but after clipping we want to maintain with higher presence well so you told about the mode if you know what is the role of remote app in there

it might have been um basically it's a neuroprotective agency rather than it is preventing the vasel spasm because because spasm could

be one of the mechanisms for the like delayed Circle ischemia but there is an independent uh like occurrence of fertility also so it is shown that uh the

um the outcomes uh like the neurological outcomes are better and uh you know and by preventing the uh delayed several ischemia

okay so you are giving us a prophylaxis for the uh to prevent related risk factors were in uh which type of

patients will be more prone for delayed Circle ischemia versus parallel the patients with intraventricular

extension uh more the extension like blood in the ventricles are more chance that they may go ahead and they may have a delayed cerebral ischemia the chances

are more with things here the fish are bit more if the as the official grade increases the chancellor versus may go up to 45 percent at the rate of grade four

during this period also to be taken care and hyperglycemia also uh associated with the delayed civilization you know when you start seeing them as passive

spasm and when will be the peak a 4 to 14 is usually 4 to 14 days is the time period where the elasticism is likely due to four days it will start

and pick around six to eight days like that and it can go up to 14 days you know how to monitor that um we conscious state is the best thing to

assist what is our Baseline and then daily monitoring like of heavily if possible uh the conscious state will tell us if she's having any drop in GCS

and uh we should attend these inconsistent then the serial clinical examination will give a clue did the patient is in an unconscious State then the serial uh

transplant your adopter monitoring along with on this B can give a clue of ongoing versus problem with raised acid then we will have the mean like mean

flow velocities will be corresponding means flow velocities will be there soon so like normally 120 if it is 120 to 140 then if it is more than 50 of this

person then more than 190 if in case of CBS passing then we will find the mean flow velocity is more than 200 centimeters per second we should use its

once again is conscious monitoring the transparent dropper is very important because uh tcd will pick up the vasus spasm almost 24 to 48 hours prior to the neurological

deficit that is wherein you have to pick that and then once the neurological deficit sets in we have to address with an intervention there

okay so serial monitoring taking the Baseline value of main flow velocity and then serially daily monitoring if there is a

worsening of the GCS neurological deficit then twice a day or twice a day based on that and if there is a Serial increase then you alarm the Interventional data list and then keep

in the loop if there is a starting of neurological Devastator that is wherein you have to introduce what medications you'll use what are the intervention you will do if there is a rascular spasm

oh this is actually um usually done by the Interventional uh Radiologists where we can directly inject uh the vasodilating agents like

papaverin or mil ring on or other agents like nanocartipine and also Verapamil but we

we have seen a doing with mil renon and peppermatics most commonly pepper Valley arterial has shown very good benefit

usually they will use introitel into the MCR ACA wherever the spasm is uh they will get a new model pinpoint for one milligram after that if it is persisting

then usually pepperoni will be used in the interoperative where they will collapse now if there is a process person directly they will indent into that and the people do use during that

relation and Will Rain on also study from demands has shown very good benefit and melanon infusion we use use

for preventing and treatment of spasmodipine dosage for prophylaxis is completely different from the therapeutic Doses and for prophylaxis we

use on the day of on the day of diagnosis 60 million fourth hourly as a tablet we'll use as an infusion for treating vasospasm if there is a continuous

hypotension or something like that we can use an original along with that but continue Milan so that it will address nicely and then the neurological deficit

even if there is a in fact in the MRI also slowly it will improve complete recovery will be there for the patient and if required uh if the spasm is increasing if you are not able to break

this panason we can repeat the intervention by giving the injection under there are many other interventions like stinting all those things and all

that it's we can discuss it later so apart from this this is the important actually it's a because Harley will see as you told Dr Ramesh told that Harley

will say uh means the signs and symptoms in terms of a spasm will be let neurological symptoms will be later person might be having a radiological basis spasm and the person neurological

signs and symptoms will be late or may not be there because I hardly will say 30 to 40 percent cases so for that reason a close monitoring with the with the interval City ngos

also will be helpful Whenever there is a high degree of Suspicion we should go for a DSA and you once you confirm your diagnosis that significant vasospasm

Iris for a DCI then that 10 definitely you should go for reverse dilator as an entire

stenting sometimes uh the uh stunting if required you can go for standing also so how will you differentiate in a

transparent after a case of suburconic hemorrhage going for vasospasm compared to hyperemia both will have high flow velocities high mean

flow velocities yeah that is when we have to comprehensively look with the lending address integration what is that

leading ratio set line ticket ratio is the ratio between the like mean flow velocities in the middle circle where the extracranial part of the uh internal

carotid arteries so if that ratio usually one to two is the normal so more than two is abnormal and more than six is serious

presence in between three to six it is again moderate yeah two to three it can be mild spasm with hyperemia if it is more than a four

five six hundred it will be more of iso space a moderate to severe rhizospasm this is the main flow velocity um grading what you told more than 120 of um

circulation is same as the positive circulation or is it different ly circulation do you say do you use the same value of 120 of mean flow velocity

now there it is noticeable at reset so definitely it should be different yeah so in the anterior circulation mean flow velocity of more than 120 is significant in the postal circulation

beam flow velocity of more than 70 is significant so there svra ratio will come and if it is more than two that is considered as spasm in the posterior circulation

okay okay so you you told about to dsno what is the role of DSA in suburbanon hemorrhage

so this is considered as a gold standard for uh like diagnosis and also for the treatment uh like um endovascular

coiling and uh so usually despite doing a CT several NGO sometimes we miss uh subarachment like annually sensor so it

is always better to go ahead in case of high suspicion to go for uh like a digital subtraction angiogram if you're still suspicious maybe we may have to

repeat it also in the later date um so yeah it is both Diagnostic and therapeutic and it is considered as a world standard for planning the

management of subarcon hemorrhage and we can know the size of the aneurysm whether the rupture is there or not neck what is the location of the aneurysm and

then what is the size of the neck also which is more important for planning of coiling or clipping or something like that so uh we can plan the management based

on that kind of the eyesight and Brad uh data analysis no entry circulation as you told it is more we can go for clipping and possible more for coiling uh basilar artery aneurysm is more

amenable for coiling it is very easy for coiling from them compared to middle circle artery and if the patient is having a large intracellular bleed with an aneurysm uh then more probably

surgical option is better with the decomposite character and then the clipping we cannot and if there is a hydrocephalus Associated then do the surgery with the ventricular petroleum

scent or the ABD to monitor the blood pressure and so as you told the wide neck candle a surgical option is better than the small nickel but whatever it is the

intervention it's better to be done within 24 hours as early as possible because of the risk of free bleeding when is the risk of rebreeding uh more like how is the pattern of re-bleeding

within 24 hours there is high risk either four percent of four to ten percent they have a chances of high re bleeding as the days increase this the chances will be one to two percent per

day per week mm-hmm okay the blood pressure is also important suppose suppose the person's blood pressure is very high

so you need to control the blood pressure how will you manage blood pressure what is your target blood pressure before securing of the aneurysm sir we

can only 90 to 100 after securing up before securing of the Indigo which should reduce the battery up to 140 by 90. uh

because we have to maintain the adequate persuasion uh in respect to the ICP and after the securing of the aneurysm to contract with the expected worth of problem now

we have to Target in a bit higher between 160 by 9200 which can be repeated for five to ten minutes and other one are as smaller and others are transition final blockers can

be used in in emergency it is a hydrologism like a 20 mg every 10 minutes any precautions for idealism

any precautions for hydrology before giving hydrology and imprecautions yeah the patient is having underlying coronary artery disease it should be

avoided hydrologist and second why don't you consider for a ntg or a nitroglycerin okay

simic acid before securing of the aneurysm and the anxemic acid can be used so the

studies are in concrete which trial was that the trial they have done said um

but previously the that um the time frame going for the surgery was a bit delayed but as per the current recommendations everything 24 hours in a

good grade we have two priority should be the securing of the annual role of steroids closer any role of fluorocortisone or

mineralocorticoids or put salt wasting in those patients the floater person has a root so this patient recovered from the acute

episode you did the clipping and he she went to what um after three four days she had presented with you with altered sensorium how will you evaluate

[Music] the first bottom and delayed the celebrity ischemia has to be identified by Imaging cell either by plane City or ack and

geography um second other causes can be can be reblade or development of the hyper coupler another reason can be an infection and another can be an

electroly disorder either hyponatum or hyponatremia or dysglycemia and these are the most common things and secondary it can be in

infected Focus anywhere in the body and a non-infectious causes of the fever can also be has to be evaluated these are the things first we have to

evaluate and proceed accordingly will be suspicion will be always okay can the patient has can can those

can they present with three blade after a clipping or coiling also is there uh if if another aneurysm is there and which we have missed then the

probability is also there that unlikely and uh but the patient has proceeded with the Indo Western calling there can

be amazing less than one person chances to one percent is a incidence of free bleeding in after post coiling and uh clipping and all so hydrocephalus also you should keep in the differential

diagnosis because the interventory Hemorrhage can go for a hydrocephalus they can also present with some Alterna

if the patient is having a sodium is of sodium of 121 uh how will you manage here the sodium the deselectrolythmia in these subregular cases it should be due

to this uh like um due to immoral and neuronal uh like disturbances so either it could be sidh or it could be in a cerebral salt

wasting syndrome so if it isn't set wasting syndrome maybe we should consider giving fluids and sixth hourly or fourth hourly monitoring of the serum

sodium if it is an essay ADH then we should restrict the fluid and then close monitoring of the sodium despite where we are not able to give

maybe we should consider two weapons how will you differentiate between those two uh sir uh the serum both are two hyponatremia cells so the serum

osmolality is a list in both and urine osmolarities uh more in hyper smaller in both and the main differentiating feature is it is

uolumia in sidh and it is hypovolemia in a cerebral salt wasting syndrome and one more differentiating feature is fractional filtration of the uric acid after correction of the hyper like

hyponatremia is it will become normal in case of sidh but it is still elevated in case of cellulose harvesting syndrome

um so only after correction I think we will know for me as far as I'm a role of any infrared spectroscopy these are the advanced

administer so whenever there is a uh versus happening in that way in that area of the involvement of the brain there can be a decreased oxygen can

happen and this near infrared spectroscopic and identify the difference in the Spectrum different changes so this can give a clue or like

the ischemic penumbra part we can identify it and we can intervene so what are the bad prognostic markers for a severeign

at the time of presentation and poor GCS at the time of presentations so these are the poor prognostication factors High intraventricular extension

higher volume of interventricular Extinction is having a re-blading within 72 hours that is also high risk for this our

person is developing a DCA means cerebral is severe vessels spasm and DCA suppose patient doubles that is also a poor prognostic Market because a person

develops systemic event and with the neurological deficit secondary to this Theory then that is also poor Progressive Market that's right so

these signs are there then because you need to prognostic at the patient Dr Ramesh first asked you that uh you need to prognosticate the patient uh

depending on the clinical status and anticipating the complications so we need to know what the patient is having and what is your expectation

chances of recovery so then accordingly can promote the question so since we are discussing about delayed service any role of Triple H therapy

what is the role of Triple H therapy in prophylactic Triple H therapy and therapeutic Triple H therapy anything is any role is there closer it is nowadays

we are not following Triple H therapy because it is leading to more of a cardiopulmonary complications already a patient will have this like a neurogenic

pulmonary edema and neurogenic like standard myocardium so very little further complicate the patients so nowadays we are targeting it to you

alimia and uh we're not like a higher like going for Triple H C what we should always hypovolemia we have to maintain the patient in uvolumia

and the target how we should keep in the late cerebral similar vasospasm in that three one one hatch we are still following them

if if we are able to maintain her basement pleasure and without any features are delay celebration then we can maintain that preparation if there

is a patient has developed any features of focal deficit secondary to office for them then we can go up to 160 by 80 and even if the symptoms are still

persisting we can go up to 200 by resistoric temperature of 200 if the if there is no end organ dysfunction due to

the hypertension uh we can go up to sister period of 200. till uh we uh decrease the symptoms of uh focal symptoms meanwhile we have to plan for

uh DHA procedure with intra arterial drugs angioplasty I mean with the angiocracy foreign

support to maintain the blood pressure that time you need to reduce the dose of pneumo dependence you can in frequency you can increase like instead of fourth

hour you can go for second hourly yeah 30 mg second hour you can go suppose not a requirement is not there you can continue with system this

support hourly if not a requirement is there better to you decrease the dose increase the frequency any role of brain specific biomarkers

[Music] pyruvate ratio uh so when the lactic pyruvate ratio will indicate uh whether it is happening any anaerobic metabolism

due to focal ischemia in this in those patients so these are the two things where we can use uh to know the regional cerebral perfusion and Metabolism

happening in the area of the office area of the brain [Music] like tissue oxygenation which should be

which should not be less than 20 and again the like jugular jugular oxygen saturation

which we should Target above 55 so if it is less than 55 again more chance of ischemia if it is available and

will you start a DVD prophylaxis and what type of DVD prophylaxis we use if the patient is going for coiling then

actually in this patient or like we um like intermittent compression stockings we applied on day one cell and if we are going for endovascular coiling after

discussing with the surgeons then on the day we can start according to the evidence if it is going for the clipping after third day we can discuss with the selection and then good sequential compression devices

mechanical compression device and then we can go for format [Music] um so any role of that stands diverters

you heard of yes there have been a large aneurysm is involved in these patients the flow diverters can be used and another is the balloon devices can

be used for diverting now what is the problem with that why we are not routinely using that

and stuff rupture is also more and then the chance of blockage uh centromocisional is more it is more thrombogenic candle and we have

to continue anti-plated Filipino once we insert that stand we have to contain the anti-plated Dual anti-plated therapy we have to continue okay

and things yeah it's uh um yeah I think of anything further what happened to your patient can you just uh

summarize your findings said bye like um like she um her until day five she was a fine sir like on day two like

day one we have taken for the surgery day two we could extubate her and then day five she had a new onset uh fever and then uh she her sensorium has become

little drowsy so then we have repeated MRI so so vocal like diffuse a weighted image restriction was there but there was no significant drop in the sensorium

but her fever spikes once it is being subsided then her sensory was really getting better like around by day eight it was better The 4K what we found was

like um we have changed the Foley catheter and then sent the cultures where we could culture Eclipse Allah which was Android resistant and we had

we started our one call listing and then she was eventually improved so on day eight we could shift out of Isis and

then by day 12 she was discharged okay so cause for deterioration in the sensorium in between was due to infection here in your case she also had

the lateral rectus palsy on the left eye cell like she was not able to uh like abduct so that is when they even thought like we should go ahead with MRI so they

repeated like then you could find any cause for lateral pulses oh no sorry no significance foreign

okay it was a good presentation um so I think it's important topic actually it comes in the exams for anyone this uh and so many complicated

things also you will see it is a basically this case in this case scenario you found that uh initially present presentation clinical

severity was less and the passenger's clinical stable you could diagnose person presented after two days to the hospital and with MRI you confirm you

had a diagnosis and then after that you went for uh clipping and the percentage improved significantly without any complications but there are so many scenarios you will

see uh different complications in subarachinal hemorrhage so we need to remember how to monitor The Peasants what to look for so like

whether is a risk for any rebuilding this foreign so yeah so yeah so there are a couple of questions that basically if the patient

who is an anti platelets are oral anticoagulants if they develop sh what is your approach to management other than the whatever we discussed

yeah so I'm basically uh if a percentage on and tip platelets we need to uh uh with all the antipolator at that point of time and we need to identify if there

is aneurysm uh energismal essays so first we have to uh energy money we have to close the end region either by clipping or a coiling so once it is done

again you can restart the antipolatelet whatever the indication whether it is underlying Mi or whatever the indication we need to continue the entity and we need to monitor for the

coagulation parameters also two at that point of time so otherwise no specific treatment no need to give any like a platelet transfusion those things are

not indicated yes sir if there is a if the patient is very high elevated INR yeah your anticoagulants and there is in the

context of bleeding entertainment subtracting so is there any role of going for the program in complex concentrate initially to uh not to

worsen further the bleeding end or so probably the connection may be very poor grade sh and or maybe initially to reverse whatever the anticoagulant effects

[Music] yeah yeah so you can con we can give a four Factor PCC because we INR is so if usually if

your target INR you want to keep between two to three and if it is more than three suppose more than five usually so uh definitely there is an indication for a four Factor PCC

and between three to five also you don't consider unless person condition is worsening so more than five definitely there is indication for for Factor basis

and yeah yes so uh what are the cardiac complications that can be possibly associated with the shift civil research

complications usually present with mostly uh they will present with like a duty prolongation and other test depression tube of inversion different

uhmias or ventricular premature complexes these type of AC changes coronary events even so many studies also there

uh it was published also that the simultaneous with Savar Hemorrhage coronary events are acute coronary events are less but to rule out when you

have a high suspicion patient have some typical chest pain underlying diabetes or some other comorbid conditions are there and uh you see the changes are typical you have a high suspicion then

that time you need to go for an NGO to go confirm your diagnosis and so there is another question from Prashant Prashant so patient passage

with acsmi simultaneously both are having so is having but couldn't find any cardiac aneurysm from BSA to Clipper coil what to do at this time anti-plate fits around you

no no I could not get suppose both are there and plus sh is there but sis there is no another system you are saying no yeah that's what you are especially but

uh it's unlike yeah yeah suppose if assets aneurysm is not there so you are not able to clip if you don't find any cause it is a non-energizimal management

and you need to you suppose you search for whatever the calls for why it has happened whether it is a traumatic or something so that point of time uh the

person neurological status is stabilized for at least 14 to 72 hours and you can consider for a antiplatelet and simultaneous Evolution for an angiogram

coronary angio to look for percentage having a blockage is there or not if no blockage no need for antipolability

yes I think uh simultaneously having ACS and Sh definitely it's a difficult scenario and difficult to manage uh case

basically okay uh next uh otherwise yeah no other questions sir I think there is another question which is how to manage SCS secondary to dabf that is Ural I

think arterial venous fistula I think it's mostly because of some venous hypertension and all but otherwise uh nothing much uh only the manage symptomatically in these patients not

much of any um actually in the spinal cord usually they go for surgery only yes sir I think

with this I think we will uh we are coming to the conclusion of the session I think it was a elaborate discussion happened I think from all languages uh

both uh and uh Dr Ramesh both uh totally covered everything I think most of the students get benefited with this uh session so thank you very much sir for

both of you uh Dr and Dr Ramesh for coming on board to uh and uh posting this session so um I thank Dr srikanth and Shilpa uh Dr

Shilpa for bringing out this case uh which is really uh our language it almost touched and you uh I think answered very well across all questions

so thank you very much sir I think this will conclude the session any final remarks you want ramesha procedure please go ahead as early as possible and then knowing

the complication we have to keep on monitoring for the complications not waiting for technological Dempsey to develop early addressing the complication early is always better

thank you thank you sir yeah thank you thank you Dr venkat for giving opportunity for uh

it was a good guest discussion and uh Dr srikant and Shilpa both presented well and I think it was a good discussion

thank you Dr Ramesh also thank you sir so we conclude the session good night friends uh you can keep listening to uh master classes thank you