1. Management of Ruptured Cerebral Aneurysms with Poor Grade SAH (Grade IV and V) Prof. Dr. Leónidas M. Quintana Prof. Dr. Leónidas M. Quintana Department of Neurosurgery – School of Medicine Department of Neurosurgery – School of Medicine Valparaíso University - Chile Valparaíso University - Chile

2. Management of Ruptured Cerebral Aneurysms with Poor Grade SAH Treated Ruptured Cerebral Aneurysms (%) 1990-2009 Total: 929 cases Total: 929 cases

3. Management of Ruptured Cerebral Aneurysms with Poor Grade SAH IV V

4. CT Scan at admission...... It makes the difference between the posterior management ( explained in the next slide) and prognosis Pattern 1- Critical brain damage 2- Brain swelling and/or edema 3- Acute Hydrocephalus 4- Intracerebral Hematoma 2 3 4 1 Management of Ruptured Cerebral Aneurysms with Poor Grade SAH

5. Initial Medical Treatment 1-ABC *Control blood gases- If GCS< 8 : Intubation *Controlled ventilation- avoid hypoxemia *CPP Management avoid hypotension (unclipped 120-150mmHg. Systolic blood pressure) ; adecuate Central Venous Pressure (6-12 cm H 2 O) 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 < 8: ICP Monitoring ; EVD or Spiegelberg system HSS 1 ICP monitoring 2 Manitol Comfort measures Hyperventilation Surgery 3 EVD 4 “as soon as possible” Management of Ruptured Cerebral Aneurysms with Poor Grade SAH

6. 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 Management of Ruptured Cerebral Aneurysms with Poor Grade SAH

7. 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

8. 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%) Management of Ruptured Cerebral Aneurysms with Poor Grade SAH

9. Compare brain edema……….. no or slight……………………..mild to severe parenchymal fragility no……………………………..yes parenchymal fragility no……………………………..yes blood-hardness of clots easy to aspirate……..………….difficult to aspirate blood-hardness of clots easy to aspirate……..………….difficult to aspirate Left ICA- Ant choroidal An <24 hours Op. 96 hours Op. <24 hours Op. 96 hours Op. TIMING OF SURGERY Right MCA An

10. 6 months follow up of 139 clipped aneurysms cases FUNCTIONAL STATE 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 % Management of Ruptured Cerebral Aneurysms with Poor Grade SAH Total Mortality of Poor Grade SAH (n= 214 cases) 53,7%

11. 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)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.Early management courses until 48 hours after initial bleeding. After that period is late management.After that period is late management. Not all grade IV&V patients have the same “damage pattern”Not all grade IV&V patients have the same “damage pattern” “Not all cases fall in the same bag”, as you can see in these images..... “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 Management of Ruptured Cerebral Aneurysms with Poor Grade SAH

12. 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 Pre topical application Post topical application Vasospasm

13. Some considerations, that can aid to improve complications......... 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 100:215–224, 2004) WE APPLY THE SAME CONCEPT WITH ON LAY SUBARACHNOID DRAINAGE “The V ventricle” Management of Ruptured Cerebral Aneurysms with Poor Grade SAH Vasospasm

14. 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 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 55:1050-1059, 2004) Pre Op. 6hrs Post Op.

15. THANK YOU VERY MUCH !!! Prof. Dr. Leonidas M. Quintana Prof. Dr. Leonidas M. Quintana Department of Neurosurgery – School of Medicine Department of Neurosurgery – School of Medicine Valparaíso University - Chile Valparaíso University - Chile