Ebook The practice of emergency and critical care neurology: Part 2
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Ebook The practice of emergency and critical care neurology: Part 2
PART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2medical institutions may admit 50-75 patients with an aneurysmal subarachnoid hemorrhage (SAH) a year. A multidisciplinary team is required to respond to the immediate needs of the patient and to plan for repair of the ancurysm.#tỉ'ẴUWM1/> Expertise may prevent poor outcome.”-47-1”After aneurysmal r Ebook The practice of emergency and critical care neurology: Part 2upture, 10% of patients die suddenly or within the first hours before ever receiving adequate medical attention. Many of these patients had marked intEbook The practice of emergency and critical care neurology: Part 2
raventricular extension of the hemorrhage and acute pulmonary edema, both reasons for sudden death.144 of those most severely affected who reach the ePART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2nd required prolonged cardiopulmonary resuscitation. Patients who survive a major first rupture face the immediate risk of catastrophic rebleeding, rapidly developing hydrocephalus, potentially life-threatening pulmonary edema, and cardiac arrhythmias. Presentation in a poor clinical condition often Ebook The practice of emergency and critical care neurology: Part 2 indicates that the hemorrhage is not confined to the subarachnoid space but rather there is intraventricular and intraparenchymal extension. Many havEbook The practice of emergency and critical care neurology: Part 2
e additional large ventricles and are in need of CSF diversion with a ventriculostomy.Ihe critical steps in managing SAH are to surgically dip the anePART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2Aneurysmal subarachnoid hemorrhage is a prime example of a neurocritical and neurosurgical disorder where outcome in the first days after presentation cannot be judged adequately and care of the initially comatose patient can lead to a satisfactory outcome.Fortunately, a considerable proportion of p Ebook The practice of emergency and critical care neurology: Part 2atients with SAT I present with severe headache and are alert with little other findings. Early repair of the aneurysm may result in an excellent outcEbook The practice of emergency and critical care neurology: Part 2
ome.CLINICAL RECOGNITIONIhe incidence of aneurysmal SAH varies, but overall is 10 cases per 100,000 persons per year (doubled in Finland and Japan)."2PART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2 more common in patients with a family history of SAH,101 polycystic kidney disease, systemic lupus erythematosus, or Ehlers-Danlos disease (Capsule 26.1).40*1Aneurysmal SAH maybe manifested in many ways. Typically, an unexpected instantaneous headache warns the patient of a very serious disorder an Ebook The practice of emergency and critical care neurology: Part 2d is often described as excruciating and overwhelming113 (Chapter 4).Vomiting may occur several minutes into the ictus as a result of further distribuEbook The practice of emergency and critical care neurology: Part 2
tion of blood throughout the subarachnoid space. Profuse vomiting may override the headache and has been mistaken for a “gastric flu” by the patient oPART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2al ICƯ (cardiac resuscitation and pulmonary edema), gastrointestinal service (vomiting), or coronary care unit (cardiac arrhythmias with new electrocardiographic [EKG] changes). Other unusual clini cal presentations have included acute paraplegia (anterior cerebral artery aneurysm rupture into front Ebook The practice of emergency and critical care neurology: Part 2al lobes) and severe thoracic and lumbar pain caused by meningeal irritation, lhese pre senlalions may have resulted in a delay in cranial computed toEbook The practice of emergency and critical care neurology: Part 2
mography (CT) scan imaging.The abruptness of the headache is not specific for SAT I; it may occur in conditions such as arterial dissection, pituitaryPART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2 lose consciousness. Inappropriate behavior and agitation or drowsiness may follow. Localizing neurologic findings, although transient, may indicate thehttp://internalmedicinebook.com318 PART VII: MANAGEMENT OF SPECIFIC DISORDERSCAPSULE 26.1 ANEURYSMAL RUPTUREWhat causes aneurysms to rupture is puzz Ebook The practice of emergency and critical care neurology: Part 2ling. Risk factors have included recently documented enlargement (rupture of aneurysms < 4 mm is uncommon; most ruptured aneurysms are 7-8 mm, and risEbook The practice of emergency and critical care neurology: Part 2
k of rupture increases significantly in aneurysms of £ 10 mm),®3 hypertension, cigarette smoking, and family history of aneurysms and SAH. Aneurysmal PART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2aneurysmal wall.160 However, at least 50% of patients have SAH while at rest. Seasonal changes have been implicated with increased rupture rate during colder temperatures and influenza peaks. An association between a recent infection and aneurysmal rupture has not been definitively established, but Ebook The practice of emergency and critical care neurology: Part 2is plausible.Inưacranial pressure rises dramatically to at least the level of tire diastolic blood pressure, causing cerebral perfusion standstill. ThEbook The practice of emergency and critical care neurology: Part 2
e increase in intracranial pressure decreases within 15 minutes but may persist if acute hydrocephalus or a shift from intracerebral hematoma has occuPART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2d computer models. Variables that may determine rupture are wall shear stress, intra-aneurysmal flow velocity, and inflow jet and angles of entry and vortexes. Wall sheet stress is caused by the frictional force of blood, and areas with high forces may fragment the internal elastic lamina and cause Ebook The practice of emergency and critical care neurology: Part 2blebs and aneurysms.56443Hemodynamic sưess may cause morphologic changes involving the endothelial lining of the walls, with intimal hyperplasia, andEbook The practice of emergency and critical care neurology: Part 2
organizing thrombosis. Many ruptured vacular aneurysms show inflammatory changes, with infiltrating leukocytes and macrophages promoting fibrosis. OthPART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2ation.20'21Subarachnoid hemorrhage. Left: aneurysmal rupture causing diffuse subarachnoid hemorrhage. Right: Vortex formation in aneurysm.site of the ruptured aneurysm. For example, patients with a ruptured middle cerebral artery (MCA) aneurysm may have transient or persistent aphasia. In patients w Ebook The practice of emergency and critical care neurology: Part 2ith a ruptured MCAaneurysm and intraparenchyma] extension, hemiparesis often is found. Abulia most often occurs as a complication of a rupture of an aEbook The practice of emergency and critical care neurology: Part 2
neurysm of the anterior cerebral artery (ACA). Generalizedhttp://internalmedicinebook.comChapter 26: Aneurysmal Subarachnoid Hemorrhage.11VFIGURE 26.1PART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2ge also known as Terson syndrome. Bottom middle: Improvement in vision. Bottom right: Normal red reflex as shown by retro illumination with fundus camera.tonic-clonic seizures are not quite so often seen at the time of rupture, and it is possible that extensor posturing or brief myoclonic jerks with Ebook The practice of emergency and critical care neurology: Part 2 syncope at onset may be mistaken for a seizure. These clinical features in SAH are identical whether or not an aneurysm is detected. Different presenEbook The practice of emergency and critical care neurology: Part 2
tation is expected, however, in an established benign variant of nonaneurysmal SAH, so-called pretrun-cal or perimesencephalic SAH. The patients are aPART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2han a second.Neurologic examination reveals neck stiffness in most patients, except those seen early after the initial event and those who are comatose. Nuchal rigidity can be demonstrated by failure to flex the neck in the neutral position and failure of the neck to retroflex when both shoulders ar Ebook The practice of emergency and critical care neurology: Part 2e lifted. Retinal subhyaloid hemorrhages are present in approximately 25% of the patients (Figure 26.1). (This syndrome is more often observed in comaEbook The practice of emergency and critical care neurology: Part 2
tose patients and after rebleeding.) These flat-topped hemorrhages occur when outflow in the optic nerve venous system is suddenly obstructed by the iPART VII-------------------Management of SpecificDisorders in Critical CareNeurologyhttp://internalm'ok.com26Aneurysmal Subarachnoid HemorrhageMajor m Ebook The practice of emergency and critical care neurology: Part 2o the vitreous (Terson syndrome).131 Cranial nerve abnormalities occur infrequently in SAH unless a giant basilar artery aneurysm (third- orsixth-nerve palsy) or a large carotid artery aneurysm (chiasmal syndromes) directly compresses surrounding structures. The pupil is dilated and unreactive to li Ebook The practice of emergency and critical care neurology: Part 2ght in a third-nerve palsy because of compression of the exteriorly located fibers that form the light reflex. However, up to 15% of posterior communiEbook The practice of emergency and critical care neurology: Part 2
cating artery aneurysms may occur with a pupil-sparing third-nerve palsy. Aneurysm of the basilar artery may produce unilateral or bilateral third- orGọi ngay
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