?a???s?as? ?e??stat????

1
?a???s?as? ?e??stat????
?????????????S ???????G??S S?? ??T
?.??????T??S ?.????S
2
?as??? S?µe?a S????asµ??
1.??????????G?? 2.????G????S ???????? 3.???????
?????OS? 4.????????S ? T???????
???S 5.???G?OS???? ??O??????? 6.?????????S?
?????? 7.S?????????S? ??? ???G?OS?????
????G????S 8.G????? T?????????? ????? 9.????S?
???? ?? T??????? 10.???G??S S?GG??????
????????????S
3
G??a??a 72 et??, ? ?p??a ??s??e??ta? st??
?a???????? ??????? µe d?????s? a?t?µat??
?pa?a???e?d??? a?µ???a??a?,e?s??eta? st?? ??T
d?as?????µ??? ?p? ??? p??? ?p?st????? ??t????
?e?t???????.
4
?p?d?µ??????a

• 6 7 pe??pt?se?? a?? 100.000 p????sµ?? t?
  ?????1.
• 20 a?? 100.000 st?? F???a?d?a ?a? t?? ?ap???a2.
• ??a? ?e????? ?at??? µe 2000 as?e?e??, ?a de?
  pe??p?? ??a as?e??
• µe ?pa?a???e?d? a?µ???a??a ???e 7-8 ?????a.
• ?? ?a? ? ep?pt?s? a????e? µe t?? ?????a, ??
  µ?s?? as?e?e?? e??a?
• ?e?te??? t?? 55 et??1.
• ?? 85 ?fe??eta? se ?a??? a?e???sµa, st? 10
  p???e?ta? ??a µ?
• a?e???sµat??? pe??µese??efa???? a?µ???a??a,
  st? 5 sp???a a?t?a

1. Stroke 2000 31 1843-50
2. Stroke 1996 27 625-29..

5
(No Transcript)
6
?? a?e???sµat??? pe??µese??efa???? a?µ???a??a

• ????e?ta? ??a ??a a??? t?p? SAH
• ?? a?µa pe??????eta? st?? de?aµe??? ???? ap? t?
  µese???fa??
• F?s???????? a??e????af?a
• ? a?µ???a??a de? epe?te??eta? st?? ?????e? ? st?
  e??efa???? pa?????µa
• ? p?????fa??? de? ??e? t?s? ??e?a ??a???, ?a??
  GCS e?sa?????, de?
• pa?at??e?ta? ?p?t??p? t?? a?µ???a??a?, de?
  d?ap?st??eta? µe?a?µ??-
• ?a???? ?s?a?µ?a, µ??? ?d????fa???.
• ????st? a?t??????a (???? f??ßa?)- ?a?? ??ßas?.

7
(No Transcript)
8
? as?e??? µa?
?t?µ??? ??aµ??st??? - ??t???a?? ?p??tas?
- F?eß???
??ep???e?a ??t? ?????
- ?pe?s?d?a pa????sµ???? ???p????
µa?µa?????
- ??ep???e?a a??t???? ?a? µ?t??e?d??? ßa?ß?da?
- Sa??a??d??
??aß?t?? -
G?a???µa
9
?a?????te? ???d????

• ?a a?e???sµata de? e??a? s???e??, a?apt?ss??ta?
  ?at? t? d????e?a
• t?? ????1.
• ? s????t?ta a?e???sµat?? ??a ??a µ?s? e?????a
  ????? pa?????te?
• ???d???? e??a? 2-3.
• ?? ??p??sµa e??a? ? s?µa?t???te??? µetaß??t??
  pa?????ta? ???d????2
• ??t???a?? ?p??tas?, ?pe?ß????? ?ata????s? a?????
  d?p?as??????
• t?? ???d???.
• 1??ßa?µ?? s???e?e?? as?e??? µe SAH ????? 3-5
  f???? a???µ???
• ???d???3.

1.Stroke 1998 29 251-56.
2 J Clin Epidemiol 199144(9)933-9. 3
Neurology 1999 Jan 152(1)34-9.
10

• Ge?et???? pa?????te? ?p???f?a ????d?a
  pe???aµß????? a?????a p??
• ??d???p????? s?stat??? t?? e????tt???a? ??s?a?.
• Fa????p??pa???aµ??? (?atasta?t??? t?? ??e???)1.
• ???e??? ??st??????? - ta a?e???sµata s????te?a
  se ???a??e?
• - p???
  t?? eµµ???pa?s? µe??µ???? ???d????2
• 
  - ???a??e? µet? t?? eµµ???pa?s? p??
  pa??????
• 
  ??st?????a, ????? µe??µ??? ???d???3
• ?e? ?p?????? epa??? ded?µ??a ??a t? p?s? ?
  a?t?p??t??? a????
• ? ta a?t?a?µ?peta??a?? a??????? t?? ???d???.
  S?????a a???????
• t? ßa??t?ta.

1. N Engl J Med 2000 Dec 21343(25)1826-32
2 Ann Intern Med 1994 Aug 1121(3)168-73 3
Stroke. 2005 Dec36(12)2773-80. Epub 2005 Nov
10.
11
??????? ?????OS?

• ?af????? p?????fa???. ?????? e?????? se ??a ?
  ???a de?te???epta.
• (a?t?st??fa, se as?e?e?? p?? eµfa?????ta? st?
  ?e???? ??at?? µe ?af????
• p?????fa??, ? ??a? st??? d??a ?a ??e? SAH1).
• ?e? e??a? ? ??tas? a??? ? ?af???? eµf???s? t??
  p?????fa??? t?
• ?d?a?te?? ?a?a?t???st???.
• ?µet??
• ???s? ?. S?µa?t??? ??de??? ????? a?e???sµat??.
• ???a????, S????s?, ????e?s?, ??µa.
• ???e???? d?s?aµ??a se 3-12 ??e?.
• ??µ???a??e? ?at? t? ß???s??p?s?.
• ?st?a?? ?e????????? s?µe??????a.
• ?p??tas?-?p??a?µ?a-??ata?a??? st? ??G.

1 Lancet 1994 344 59093.
12
? as?e??? µa?...

• ????
• ?t?s? ep?p?d?? s??e?d?s??
• ?? ?µ?p??es?
• Babinski ?µf?
• St??f? ß??µµat?? a??ste??.

13
??????s?

• CT ? e??tas? e??????. ? e?a?s??s?a µe?a??te??
  t?? p??t? ?µ??a.
• ?e? ??e???eta? st?? p??t? e??tas? s??a??af???.

14
(No Transcript)
15
???

• 3 t?? as?e??? µe ?af???? p?????fa?? ?a?
  f?s???????? CT
• ????? st? ??? µetaß???te? a?µ?sfa?????? µ?sa se
  12 ??e? ap?
• t?? ??a??? s?µpt?µ?t?? ?a? ? a??e????af?a
  a???????? ep?ße-
• ßa???e? ??a ?a??? a?e???sµa1.
• ? ??? e??a? apa?a?t?t? se ???e as?e?? µe ?af????
  p?????fa??
• ?a? f?s???????? CT.???pe? ?a ????? pe??se?
  t??????st?? 6 ??e?
• ap? t?? ??a??? t?? p?????fa??? ( ??????
  apa?a?t?t?? ??a s??µat?
• sµ? ???e????????).

J Neurol Neurosurg Psychiatry 1995 58 357-59
1.
16
(No Transcript)
17
MRI

• ??? p??te? ??e? ?a? ?µ??e? ??e? t?? ?d?a
  e?a?s??s?a µe t? CT1.
• ??? ep?µe?e? ?µ??e? e??a? pe??ss?te?? e?a?s??t?
  st? ?a a????e?se?
• a?µa2.

1. Stroke 2004 35 50206.
2. J Neurol Neurosurg Psychiatry 2001 70
20511.
18
(No Transcript)
19
???e????af?a

• ?e? e??a? µ??? d?a???st???, ß????e? ?a? st? ????
  ?e?ape?t????
• ap?fas?? (coiling-clipping).
• ? ??as??? a??e????af?a (gold standard), ??e?
  e?a?s??s?a 951.
• Se p?????? as?e?e??, ? s?ed?asµ?? t?? eµß???sµ??
  ? t?? ?e???????
• ??? ep?µßas?? µp??e? ?a ßas?ste? se CT
  a??e????af?a2
• ? CTA p??pe? ?a ???e? aµ?s?? µet? t??
  ep?ßeßa??s? t?? a?e???
• sµat???? a?µ???a??a? µe CT, se p??t? ?????.
• ? ??as??? a??e????af?a µp??e? ?a p???a??se?
  ?s?a?µ?a st? 1-8
• ?a? ???? a?e???sµat?? st? 1-23.

1. Neurosurgery 2003 52 624-30.
2. J Neurosurg 1999 91 76167. 3. Neurosurgery
1979 5 31424.
20
St?? pe??pt?s? µa?

• ????e CT e??ef???? a?µ???a??a st? ep?ped? t??
  ßas???? ?a??????
• pe??est?a?? ??d?µa, e?d??????a?? a?µ???a??a,
  d?e????s? p?a????
• ???????.
• ? as?e??? e?s??eta? st?? pa???????? ???????. ???
  ?d?a µ??a ???eta?
• s?pt???, d?as??????eta? ?a? d?a??µ??eta? st?
  ??T. G??eta? ??a CT
• ????? ??a e???µata. ?e? ????e a??e????af?a.
• ?at? t?? e?sa???? t?? st? ??T, ?p? ?atast???,
  pa???s?a?e
• -GCS7
• - ?s??????? µe ()
  f?t?????t???
• - ?? ?µ?p??es?
• - Babinski ?µf?
• - St??f? ß??µµat??
  ??

21
Ge???? ?e?ape?t??? µ?t?a

• S??e??? ep?ß?e?? (GCS, ?e?µ???as?a, ??G, ???e?,
  ?e?????????
• e?t?µ?s?).
• ??e?te???? d?at??f?- d?asf???s? ?a???????
  ?e??se??.
• ??p???t?s? ?????ast????? s????a-ep?ßeßa??s? ??s??
  µe a/a
• ??a??? s?t?s?? µe 5 dextrose. ? as?e???
  se ?µ??a??st? ??s?.
• ?a??µßas? se a?t???a?? ?p??tas? µ??? ?ta?
  ????130mmHg
• ? se ß??ß? ??????? st????.
• ?/S 0,9 3 L/?µ??a. ??p???t?s? ?????a?et??a.
  ??e????
• ??e?t????t?? ???e 2? µ??a.
• ??e???? p???? µe pa?a?etaµ??? (??? asp?????),
  µ?da????µ? e??
• ?p???e? d???e?s?, ? ??de??? se s?ßa??
  p???.
• Compression stockings ? pneumatic compression
  ??a p??????
• ???µß?eµß?????? ??s??.

22
St?? as?e?? µa?

• ????µas?a d?e?te????? s?t?s?? µe 5dextrose ap?
  t?? 3? µ??a.
• G?a 20 µ??e? ??aße pa?e?te???? d?at??f? d??t?
  de? p??????se.
• St?? 23 µ??e? et??? ??????st?d???? s????a? ?a?
  ????e ??a???
• d?e?te????? d?at??f??.
• ??? 12? ?µ??a ??s??e?a? ?peß???? se
  t?a?e??st?µ?a.
• ???µesa st??? as?e?e??, ?? ?p???? ?a ??e?ast???
  pa?atetaµ???
• µ??a???? ae??sµ? (pe??ss?te?? ap? 21 µ??e?,
  t??????st?? 6 ??e?
• t? µ??a) e??a? ?a? ?? as?e?e?? µe SAH.
  ???te??eta? d?e????e?a
• t?a?e??st?µ?a? t?? 7? µ??a1

1. Ann Acad Med Singapore 2001 May30(3)234-8.
23
?p?p?????
S?st?µat????1

1. ???et?? (???µ?d??? ?a? µ? a?t??????a?)
2. ??a?µ?a
3. ?p??tas? ? ?p?tas?
4. ?pe?????a?µ?a. ?a??? p?????st???? de??t??.
5. ?pe??at??a?µ?a ?a? ?p??at??a?µ?a
6. ?p?µa???s?a?µ?a
7. ?a?d?a?? a?ep???e?a ?a? a????µ?e?
8. ??e?µ????? ??d?µa
9. ??e?µ???a

1. Crit Care Med 1995 23 100717.
24

• ??a µe??t? 413 as?e??? p??sd????se 4 µetaß??t??,
  ?? ?p??e?
• s?et????ta? µe a???µ??? ???d??? ?a??t?? ?a?
  a?ap???a?
• 3 µ??e? µet?1
• ?p??a?µ?a. ???e??d?a?t???a?? d?af???gt125mmHg
• ?etaß????? ????s?. (serum bicarbonate lt20 mmol/L)
• ?pe?????a?µ?a. S???a??gt180mg/dl
• ??µ?d??aµ??? ast??e?a (???lt70 ?a? ???gt130mmHg)

1. Crit Care Med 2004 Mar32(3)832-8
25
? as?e??? µa? pa???s?ase

• ?p? t?? p??t? ?µ??a PaO2/FiO2lt200
• ?p????µ?s? sa?????? (a?t??a ??s???????)
• ?pe?s?d?a ???p???? ta??a????µ?a? (e???a QRS ?a?
  µ??f?????a
• LBBB) e?a??ass?µe?a µe ß?ad??a?d?a ?a? pa?se??.
  ?t??? p??s???
• ??? ß?µat?d?t??. ?pe?ta ap? 3 µ??e?, ep? ste??a?
  a?µ??a??????e?a?,
• et??? µ???µ?? ß?µat?d?t??.
• ??e?a a????as??? ??????st?t?da. ??????ste?t?µ?,
  t?p???t?s?
• Kehr, ERCP.
• ?pe??a??a?µ?a-?pe??at??a?µ?a-?pasßest?a?µ?a-?pe?µa
  ???sa?µ?a
• ??e?µ???a

26
????a?d?a?? ß??ß?

• ???a??tata t? ap?t??esµa ape?e?????s??
  ?ate???aµ???? µ?sa
• st? µ?????d??, ???? ?p???de?s?? t?? ?p?s????
  ?p??a??µ??.
• ?p???e? s?s??t?s? ßa??t?ta? ?e?????????? ß??ß??
  ?a? ep?p?d??
• t??p?????? ????1.

1. Stroke 2004 Feb35(2)548-51. Epub 2004 Jan
22.
27
(No Transcript)
28
??d???? ?p?p?????
??a ??µ???a??a

• ?? 15 a?µ???a?e? e? ???? t?? p??te? ??e?1
• ????? ep?µßas?, t? 40 a?µ???a?e? e? ???? t??
  ep?µe?e? 4 eßd?µ?de?2
• ??? s?µße?, t? 80 t?? as?e??? pe?a??e? ?
  pa???s???e? a?ap???a.

1. Stroke 2001 32 117680.
2. J Neurosurg 2002 971036-41
29
Clipping

• ???a p?a 2? ep????? ??a t??? pe??ss?te????
  as?e?e??1
• S?????? p?a?µat?p??e?ta? ????? (?da???? t? 1?
  24???)
• Se e?d??? ???t?a µe µe?a??te?? eµpe???a ? ??ßas?
  e??a? ?a??te??2
• ? d?e??e???t??? ?p??e?µ?a de fa??eta? ?t?
  ß????e?3
• MRA ? CTA st??? 3 ? 6 µ??e?. ???e????af?a ep?
  ep?de???s??.

1. J Neurosurg 2002 971036-41.
2. Stroke 2003 Sep34(9)2200-7
3. N Engl J Med 2005 Jan 13352(2)135-45.
30
Coiling

• ?e? p??t?µ?ta? se (a) a?e???sµata µe e??? a????a
• (ß)
  pe??fe????te?a a?e???sµata
• (?) ???a?t?a?a
  a?e???sµata 1
• ? a???µ?? a?t?? t?? e?d??? ep?µßas?? d?a????
  a????eta?2.
• ?a?aµ????? e??t?µata ??a t? µa???p???esµ?
  ap?te?esµat???t?ta
• ?p?? a/a ??a???? se 2 eßd?µ?de?, 3 ?a? 6 µ??e?
  µet?. ???e????af?a
• st??? 3 µ??e?.

1. AJNR Am J Neuroradiol 1994 May15(5)815-20
J Neurol Neurosurg Psychiatry 2004 75807.
2.
31
(No Transcript)
32
??te ?a? ??

• ????µ? ep?µßas? (48 µe 72 ??e?) se as?e?e?? µe
  Hunt and Hess
• Grades 1 to31
• Good grade aneurysms
• Hunt and Hess grades 4-5 ???a??? ? eµß???sµ??
  st?? ??e?a f?s?
• ?a? a???te?a ?e????????? ep?µßas? ep? µe?????
  ap?f?a??? t??
• a?e???sµat??, e??a? ? p?? ap?d?t??? p?a?t???.

coiling2

1. J Neurosurg 1995 Sep83(3)394-402.
2. Lancet 2002 Oct 26360(9342)1267-74.
33
?s?a?µ?a

• S?????? s?µßa??e? ap? t?? 5? ??? t?? 14? µ??a
  ap? t?? a?µ???a??a.
• ? a??e??spasµ?? e??a? µ?a ap???ste?µ??? e????s?
  µ?a? ?a? ?
• µe??s? t?? a?t???a??? d?aµ?t??? de? pa?at??e?ta?
  p??ta1
• MRI, d?a??a??a?? doppler, ??as??? a??e????af?a
  ??a d?????s?
• ??ta????st?? asßest??? ap?dede??µ??? d??s?
  ??µ?d?p????2.
• ??s? 60mg ???e 4 ??e? p.os ??a 3 eßd?µ?de?.

1. Stroke 2004 35 1862-6
BMJ 1989 298636-42
2.
34
(No Transcript)
35
?s?a?µ?a

• ? a?ap????s? ?a???s??? µp??e? ?a ß????se?1
• ?e? ??e? ap?de???e? ?f??e?a ap? ???s?
  a?t?a?µ?peta??a???
• pa?a???t??2.
• Hypertension-Hypervolaemia-Haemodilution.
  ?µf?ß??? ap?te?esµa
• t???t?ta3. ?? ?d?? ?s??e? ??a t?? a??e??p?ast???
  ?a? ta a??e??d?asta?t?
• ??4.
• ?? stat??e? µp??e? ?a ß????s??? st?? p?????? t??
  a??e??spasµ??.
• ???s???ta? se pe??aµat??? st?d??.

1 J Neurosurg 2002 96510-14.
2. Stroke 2003 34 228589.
3. Cochrane Database Syst Rev 2004 4 CD000483,
4. AJNR Am J Neuroradiol 2004 25 177882.
36
?d????fa???

• ?at?fe??? ap????s? t?? µat??? ?a? µ????? µ?
  a?t?d??se? ???e?1.
• Se µe?a??te?? ???d??? as?e?e?? µe e?d??????a??
  a?µ???a??a ?
• e?tetaµ??? a?µ???a??a st?? pe??µese??efa?????
  de?aµe???.

1 J Neurosurg 1985 63 35562. .
37
CT e??ef???? ?? ??atetaµ??e? ?????e?
? 24 ??e? pa?a???????s?
? ??? ? pa????te?s? µ?s?
e?d???????? ?a?et??a
?
p??a?? ??????t?? e?? ? ?a?et??a?

pa?aµe??e? p??? ap? 3 ?µ??e?1
1. Stroke 1989 20 74753.
38
? as?e??? µa?

• ??? ?peß???? se a??e????af?a, ???
  a?t?µet?p?st??e µe
• Coiling ? Clipping.
• ??? a?µ??????se ?a??.
• ?µf???se ?d????fa??, ? ?p???? a?t?µet?p?st??e µe
  ??? ?a?
• a?eta???aµ?d?.
• ??aße ??µ?d?p??? e?d?f?eß??? ??a 3 eßd?µ?de?.

39
??t?p??t???

• ?,t? a?t?p??t??? ?a? a?t?a?µ?peta??a????
  pa?????te? ?pa???e ?
• as?e??? p??pe? ?a d?a??p??? ?a? ???e d??s?
  a?t?p??t???? p??pe?
• ?a a?ast?afe? µe ß?taµ??? ? ? FFP1.
• Pneumatic compression p??? t? ?e?ape?a t??
  a?e???sµat??.
• ?et? t? coiling ? clipping µp??e? ?a ???????e?
  ??as??? ?pa????
• ?p?d????? 5000iu ???e 8 ??e?2

1. Stroke. 2006 Feb37(2)577-617.
2. N Engl J Med. 2006 Jan 26354(4)387-96.
40
?µe??
??????saµe e???apa???? 40 mg µ?a f??? t?? ?µ??a
?p?d????? ap? t? 10? µ??a, ?ta? de? d?ap?st????e
??a a?µ???a??a st? CT
41
??t?ep???pt??? a????

• Ta p??pe? ?a e?a??st?p??e?ta?
• ??? de? ?p???e? s?µµet??? t?? f????? de? e??a?
  apa?a?t?t?
• ?f?s?? a???se? ?a? a???????se? clipping, µet?
  µp??e? ?a staµat?se?1
• ( ? µe??t? de? af????se coiling ? ?e??????e??
  µet? ap? 3 eßd?µ?de?.).
• ?s?? eµfa??s??? ???s? ?? t?? p??te? 7 ?µ??e?, ?a
  ??ß??? a????
• ??a 6 µ??e? µe fa???t????, ?a?ßaµa?ep??? ?
  fa???ßa?ß?t???.

1. J Neurol Neurosurg Psychiatry 2004
Nov75(11)1620-2.
42
? as?e??? µa?
??aße fa???t???? ap? t?? 1? ??? t? 19? µ??a ?????
p?t? ?a eµfa??se? spasµ???.
43
ICP monitoring ?a? ???µ?s? a?t???a??? p?es??

• ???te??eta? d?e????e?a ??????st?µ?a? ?a?
  pa?a???????s? t??
• e?d??????a? p?es?? se as?e?e?? µe ßa??te??
  ??????? e????a
• ?a? p?? e?tetaµ??? a?µ???a??a.
• ?a??µßas? ?ta? ? ???gt130 mmHg µe ?aßeta???? ?a?
  ???
• ??t??p??ss??? ? ??t??????e????1. ?p???µ?t?
  S??140 mmHg

1. Lancet 1992 Mar 14339(8794)653-5.
44
??ßas? µet? t? ?e?ape?a

• ?? as?e?e?? p?? ep?ß?????? ????? se ?????
  p?s?st? d?ata?a???
• µ??µ??, ??????????? d?ata?a??? ?a?
  d?ata?a?µ??? ???t???
• ?e?t?????a1. S?????? a?t?? e??a? µ???µe? ?a?
  de s?et????ta? µe t?
• ??s? t?? a?e???sµat??.
• Late rebleeding 1010 as?e?e??2

711 clipping 299 coiling
?a?e?? de? a?µ??????se ??a? a?µ??????se
sta 3.7 ?????a sta 4 ?????a
1. - Neurology 1995 May45(5)875-82.
2. Stroke. 2006 Jun37(6)1437-42.
45
(No Transcript)
46
??e???? s???e????? pe??ß?????t??
?? s???e?e?? 1?? ßa?µ?? ????? 3-5 f???? a???µ???
???d??? ??a SAH se s?????s? µe t? ?e????
p????sµ?1 ???? t? pa??? de? p??te??eta? ??e????
??a e?d??????a a?e???sµata st? ?e????
p????sµ?. Se p????sµ??? µe 2 ? pe??ss?te????
s???e?e?? 1?? ßa?µ?? µe e?d??????a a?e???sµata,
d??f??a p?????µµata ????? a?ade??e? a???µ???
ep?pt?s? a?e??es?? a?e???sµ?t??. Se a?t??? t???
p????sµ??? ??e???eta? e?at?µ??e?s?2
1. BMJ 2000 Jan 15320(7228)141-5.
2. Circulation 2000 1022300.
47
? as?e??? µa?
?????e µe GCS13 ?pe?ta ap? 4 µ??e?, µe ??e?st?
t?a?e??st?µ?a. ?p????se ?a ???eta?, s?t???ta?
p.os ?a??????.