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Episode 102: INSIGHTS - Subarachnoid Hemorrhage Pt1.

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Description

Listen to the latest episode of NCS' INSIGHTS series on Subarachnoid Hemorrhage (part 1 of 2)

The INSIGHTS series is hosted by Casey Albin, MD and Salia Farrokh, PharmD, and covers different topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource to offer content exclusively dedicated to the practice of neurocritical care. Learn more about ON CALL®.

This episode is sponsored by Biogen.

Science that transforms patient lives. Science that seeks to solve societal problems. Science that acts with purpose. Science that is inspired by the diversity and passion of our people. Discover where science meets humanity at Biogen.

The NCS Podcast is the official podcast of the Neurocritical Care Society.

Contributors

  • Salia Farrokh, Pharm.D., BCPS, BCCCP

    Salia Farrokh, PharmD, BCPS, BCCCP is a neuro ICU clinical pharmacist specialist at Johns Hopkins Hospital. Dr. Farrokh received her PharmD degree from Saint John Fisher College, Wegmans School of Pharmacy in Rochester, NY. Her postgraduate training includes residencies in Critical Care and Pharmacy Practice at Yale-New Haven Hospital. Dr. Farrokh’s research interests include effective antiplatelet therapy in neuro intervention patients, optimal pain management in neuro ICU patients, and use of neurostimulants in this setting. Dr. Farrokh is passionate about training and precepting students and residents and is a certified ENLS trainer.

  • Casey Albin, MD

    Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/BWH/MGH. She completed Neurocritical Care fellowship at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of a best-selling textbook The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, blogs, and podcasts. She serves on the Education Committee of the Neurocritical Care Foundation.

  1. 00:00:19
    All right. Hi, everyone. Welcome back.
  2. 00:00:21
    This is the Insights podcast. As you
  3. 00:00:24
    remember, Insights is based on the
  4. 00:00:26
    incredible content that's on on call,
  5. 00:00:29
    which is a continually updated online
  6. 00:00:31
    chapter textbook that is published by
  7. 00:00:34
    the Neurocritical Care Society. And
  8. 00:00:36
    today I'm back with Stalia. We have a
  9. 00:00:38
    really exciting episode because several
  10. 00:00:41
    actinoid is a and exciting topic, but
  11. 00:00:42
    also there are two new guidelines to
  12. 00:00:45
    inform this updated content. And we're
  13. 00:00:49
    really excited to dive right back in.
  14. 00:00:52
    But before we get started, a couple
  15. 00:00:54
    words from our sponsor, Biogen and
  16. 00:00:56
    Sarah Bell, and now a word from one of
  17. 00:00:58
    the sponsors. Founded in 1978, Biogen
  18. 00:01:02
    is a leading global biotechnology
  19. 00:01:04
    company that has pioneered multiple
  20. 00:01:06
    breakthrough innovations, including a
  21. 00:01:08
    broad portfolio of medicines to treat
  22. 00:01:10
    multiple sclerosis the first approved
  23. 00:01:13
    treatment for spinal muscular atrophy
  24. 00:01:15
    and to co-developed treatments to
  25. 00:01:17
    address a defining pathology of
  26. 00:01:19
    Alzheimer's disease. Biogen is
  27. 00:01:22
    advancing a pipeline of potential novel
  28. 00:01:24
    therapies across neurology,
  29. 00:01:26
    neuropsychiatry, specialized immunology,
  30. 00:01:29
    and rare diseases, and remains acutely
  31. 00:01:32
    focused on its purpose of serving
  32. 00:01:34
    humanity through science while advancing
  33. 00:01:36
    a healthier, more sustainable, and
  34. 00:01:39
    equitable world. All right, so just
  35. 00:01:43
    like I said in the intro, this has been
  36. 00:01:44
    really exciting because there's not one.
  37. 00:01:47
    There are two recently updated
  38. 00:01:49
    guidelines. One has been put forth by
  39. 00:01:52
    the Neurocritical Care Society, and
  40. 00:01:54
    then one is by the American Heart
  41. 00:01:55
    Association, the American Stroke
  42. 00:01:56
    Association, and now the on-call
  43. 00:01:58
    chapter reflects these updated
  44. 00:02:01
    management paradigms. And so, this has
  45. 00:02:05
    been a really exciting content update.
  46. 00:02:08
    The last time we had had really a whole
  47. 00:02:10
    new set of guidelines had been over 12
  48. 00:02:13
    years ago So this is fresh management.
  49. 00:02:16
    Awesome, yeah, hi everyone. Thank you,
  50. 00:02:19
    Casey. It's good to be back. As you
  51. 00:02:22
    said, this is really exciting. It's
  52. 00:02:24
    exciting enough that we're gonna do two
  53. 00:02:26
    different episodes on it. The first one
  54. 00:02:30
    will really focus on what we're gonna do
  55. 00:02:32
    in the acute phase and just stabilizing
  56. 00:02:35
    these patients. Let's say you got them
  57. 00:02:36
    in the ED, just the initial assessment,
  58. 00:02:38
    initial management. And then the second
  59. 00:02:41
    episode that we're gonna do together
  60. 00:02:42
    also is gonna focus on okay, now these
  61. 00:02:44
    patients are diagnosed and they're gonna
  62. 00:02:47
    have some complications and how do we go
  63. 00:02:49
    about those complications and management
  64. 00:02:51
    of those complications.
  65. 00:03:03
    So,
  66. 00:03:05
    Casey, let's say you get a call to go
  67. 00:03:07
    see someone in the ED, when do you
  68. 00:03:09
    actually think about sub-acronin
  69. 00:03:11
    hemorrhage? How do you assess these
  70. 00:03:14
    patients and when does that seem to be
  71. 00:03:16
    your initial first thought for
  72. 00:03:20
    diagnosing these patients? Absolutely.
  73. 00:03:23
    So one of, I think, the hallmark trait
  74. 00:03:26
    of these patients is that these are
  75. 00:03:28
    patients who present with the worst
  76. 00:03:29
    headache of life, classically. Now it
  77. 00:03:33
    is really important to remember that
  78. 00:03:35
    sub-arachnoid hemorrhage is not the only
  79. 00:03:37
    thing that causes an abrupt onset
  80. 00:03:39
    headache. You also have to consider,
  81. 00:03:42
    is this reversible vasoconstriction
  82. 00:03:44
    syndrome? Is this meningitis? Is this
  83. 00:03:46
    pituitary apple plexi? Even into
  84. 00:03:49
    prancomol hemorrhage can cause that
  85. 00:03:51
    terrible onset headache. So when I hear
  86. 00:03:54
    someone say, you know, this was a
  87. 00:03:56
    person who came in worst headache of
  88. 00:03:57
    life, then of course, my suspicion is,
  89. 00:04:00
    you know, to rule out subarachnoid
  90. 00:04:03
    hemorrhage. And what I think the
  91. 00:04:05
    guidelines have made really clear is
  92. 00:04:07
    that our threshold for scanning people
  93. 00:04:09
    with new onset worst headache of life
  94. 00:04:12
    should be very low. The American Stroke
  95. 00:04:16
    Association guidelines talk about the
  96. 00:04:18
    Ottawa imaging rule for subarachnoid
  97. 00:04:20
    hemorrhage. Going through the details
  98. 00:04:22
    of that is really not important. Others
  99. 00:04:25
    didn't just say that it's very sensitive.
  100. 00:04:27
    Basically, anyone who's coming in with
  101. 00:04:30
    a thunderclap headache needs imaging
  102. 00:04:34
    with a non-con heads ET to evaluate for
  103. 00:04:37
    whether or not they've had a
  104. 00:04:39
    subarachnoid hemorrhage.
  105. 00:04:46
    The CT scan, good, you know, up to
  106. 00:04:48
    date CT scanners are very, very
  107. 00:04:50
    sensitive at picking up acute blood.
  108. 00:04:54
    The acute or the blood, the more
  109. 00:04:56
    sensitive they are. As time goes on,
  110. 00:05:01
    the sensitivity of a CT scan diminishes.
  111. 00:05:04
    And so one of the things that I think is
  112. 00:05:06
    very interesting in this guideline is
  113. 00:05:08
    they talk about sort of the six-hour
  114. 00:05:10
    divide between the patients who come in
  115. 00:05:13
    within six hours of the ixis of headache
  116. 00:05:16
    and those who come in after six hours.
  117. 00:05:19
    For the patients who come in within six
  118. 00:05:21
    hours, if there is no sign of
  119. 00:05:24
    subarachinoid hemorrhage on a CT scan
  120. 00:05:27
    that's on a high-quality scanner, the
  121. 00:05:29
    scan is read by a neuroradiology trained
  122. 00:05:33
    radiologist, then that's it. You're
  123. 00:05:36
    done The patient doesn't have
  124. 00:05:37
    subarachinoid hemorrhage.
  125. 00:05:40
    It gets a little trickier if they are
  126. 00:05:43
    coming in. after six hours of the ictus
  127. 00:05:46
    of headache. At the after six hour mark,
  128. 00:05:51
    that's CT scan if there's any equipos
  129. 00:05:53
    and clinically you have a high concern
  130. 00:05:55
    because the patient says, you know,
  131. 00:05:56
    I'm really having a bad headache. It
  132. 00:05:58
    came on all of a sudden, it was worse
  133. 00:06:00
    right when it started. And
  134. 00:06:02
    unfortunately, you really do need to do
  135. 00:06:06
    a lumbar puncture to rule out the other
  136. 00:06:07
    chromium. Now, one of the things that
  137. 00:06:10
    I think we were hoping maybe we could
  138. 00:06:13
    get away with is MRI. And one of the
  139. 00:06:16
    things to make clear is that the ASA
  140. 00:06:18
    guidelines say there is not enough data
  141. 00:06:21
    on the use of MRI in these patients. So
  142. 00:06:24
    we cannot rely on an MRI to be the next
  143. 00:06:28
    step in our diagnostic algorithm for
  144. 00:06:30
    subarachine hemorrhage. You have
  145. 00:06:32
    clinical concerns. It's been more than
  146. 00:06:34
    six hours. There's equipose on
  147. 00:06:37
    the CT scan. That patient needs a
  148. 00:06:38
    lumbar puncture.
  149. 00:06:49
    When you find subarachnoid hemorrhage on
  150. 00:06:51
    the CT scan, it's first of all really
  151. 00:06:53
    important to look at the pattern of
  152. 00:06:55
    subarachnoid hemorrhage. I think we're
  153. 00:06:57
    all trained to be focused on
  154. 00:07:00
    subarachnoid hemorrhage, it means that
  155. 00:07:01
    there's an aneurysm and aneurysm has
  156. 00:07:03
    ruptured. That pattern of blood is
  157. 00:07:07
    usually blood within the basal cisterns,
  158. 00:07:10
    kind of at the base of the brain, which
  159. 00:07:13
    is where the circle of willis is So when
  160. 00:07:15
    these aneurysm ruptures, they put blood
  161. 00:07:18
    into the circle of willis, into the
  162. 00:07:19
    ventricle space, that's sort of the
  163. 00:07:22
    classic pattern. Chortical subarachnoid
  164. 00:07:25
    hemorrhage actually has a different
  165. 00:07:27
    differential diagnosis. We're not going
  166. 00:07:29
    to talk about that during this, but it
  167. 00:07:31
    is kind of important if you're trying to
  168. 00:07:33
    tease out, you know, is this an
  169. 00:07:35
    aneurysm rupture patient that you're
  170. 00:07:37
    looking for sort of the classic aneurysm
  171. 00:07:40
    rupture pattern, or sometimes blood in
  172. 00:07:42
    the solvian and Fisher, which can be
  173. 00:07:44
    sort of an atypical pattern. All right.
  174. 00:07:51
    All right, but let's say this is a
  175. 00:07:52
    patient, they come in, it's within six
  176. 00:07:54
    hours. They've got blood in the bit and
  177. 00:07:57
    the basal cisterns. This looks
  178. 00:07:58
    extremely concerning for an aneurysmal
  179. 00:08:02
    subarachnoid hemorrhage. Really,
  180. 00:08:04
    really important to get the patient to a
  181. 00:08:06
    high volume center. We know that
  182. 00:08:09
    dedicated neurocritical care and
  183. 00:08:12
    neurovascular surgical expertise make a
  184. 00:08:14
    big difference in these patients So the
  185. 00:08:18
    first step, if you're not sort of at a
  186. 00:08:20
    high volume subarachnoid hemorrhage
  187. 00:08:22
    center, is getting the patient to one
  188. 00:08:25
    of those centers. And then we're also
  189. 00:08:28
    thinking through kind of the top three
  190. 00:08:30
    things that can make these patients
  191. 00:08:32
    worse acutely. So they absolutely need
  192. 00:08:36
    their aneurysm treated as soon as
  193. 00:08:37
    possible to prevent one of the worst
  194. 00:08:39
    complications, which is re-repture.
  195. 00:08:42
    They also really need early treatment,
  196. 00:08:46
    or even sometimes prevention of
  197. 00:08:48
    hydrocephalus. Remember that when blood
  198. 00:08:51
    from an aneurysm ruptures, it's
  199. 00:08:54
    rupturing into the CSF space. It's
  200. 00:08:56
    causing that CSF to not circulate in the
  201. 00:09:00
    way that it normally would. And that
  202. 00:09:03
    leads to the development of
  203. 00:09:04
    hydrocephalus. This is what can really
  204. 00:09:06
    kill people. If they don't die from the
  205. 00:09:09
    aneurysm rupture, they can die because
  206. 00:09:11
    of hydrocephalus. And that is a
  207. 00:09:13
    completely treatable etiology. So we
  208. 00:09:17
    need to get them to a place where a
  209. 00:09:19
    neurosurgeon can put in an external
  210. 00:09:21
    ventricular drain or a lumbar drain,
  211. 00:09:23
    depending on how your center manages
  212. 00:09:25
    these patients. I think there's still
  213. 00:09:27
    some equipos there about which way is
  214. 00:09:29
    better. Either way, they're going to
  215. 00:09:32
    need CSF diversion. And then we have to
  216. 00:09:36
    think about, well, what are some of
  217. 00:09:37
    the things that can make re-repture more
  218. 00:09:40
    likely, and how do we prevent those
  219. 00:09:43
    things? And the two things that come to
  220. 00:09:45
    my mind are seizures We know that
  221. 00:09:48
    patients who see me. They're at higher
  222. 00:09:50
    risk of causing intracranial pressure.
  223. 00:09:52
    They can have pressure gradient changes
  224. 00:09:54
    that can cause the aneurysms to re
  225. 00:09:56
    rupture. And we know that ongoing and
  226. 00:09:58
    sustained hypertension also is probably
  227. 00:10:02
    setting the patient up to have a
  228. 00:10:03
    complication. Now the guidelines are
  229. 00:10:06
    clear and Sally, I really want to ask
  230. 00:10:07
    you, how are you thinking through what
  231. 00:10:09
    drugs to give when you think about
  232. 00:10:12
    hypertension and seizure prevention in
  233. 00:10:14
    this acute setting? Yeah, absolutely I
  234. 00:10:17
    think starting with blood pressure
  235. 00:10:19
    management, the first thing that
  236. 00:10:22
    there's a lot of debate about it, and
  237. 00:10:24
    sometimes I think honestly, it's a
  238. 00:10:25
    blessing that we don't have a specific
  239. 00:10:26
    blood pressure goal, which makes you
  240. 00:10:28
    think that every patient requires that
  241. 00:10:32
    kind of individualized blood pressure
  242. 00:10:34
    goal. So when we think about these
  243. 00:10:36
    patients, I think the first question
  244. 00:10:37
    that comes up is that is the aneurysm
  245. 00:10:39
    secured or not secured, because that
  246. 00:10:41
    alone can play a huge role for the blood
  247. 00:10:44
    pressure goal that you have You know,
  248. 00:10:46
    the patients that they don't have the
  249. 00:10:48
    aneurysm. secured yet. The problem is
  250. 00:10:50
    that you are always afraid that if your
  251. 00:10:53
    blood pressure is even slightly high,
  252. 00:10:55
    you're going to rupture that. So
  253. 00:10:56
    usually those patients have a more tight
  254. 00:10:59
    blood pressure control goal. Every
  255. 00:11:02
    institution, I'm sure, is different.
  256. 00:11:04
    Sometimes you talk about less than 140.
  257. 00:11:05
    Sometimes you talk about less than 120.
  258. 00:11:08
    But again, it's just important to note
  259. 00:11:10
    that these patients require a lower
  260. 00:11:12
    blood pressure goal. But then on the
  261. 00:11:14
    flip side, if you have a patient that
  262. 00:11:16
    requires more perfusion because they're
  263. 00:11:20
    at risk of infarction, those patients
  264. 00:11:23
    require augmentation of blood pressure.
  265. 00:11:25
    Obviously at this point, aneurysms are
  266. 00:11:27
    secured and it's a little bit down the
  267. 00:11:29
    road when we talk about that.
  268. 00:11:33
    As far as what agents to use, I think
  269. 00:11:37
    we've had this discussion in other
  270. 00:11:39
    episodes that you want something that is
  271. 00:11:41
    quick on, something that is easy to
  272. 00:11:44
    titrate. Agents that come into play are
  273. 00:11:47
    nichardopene.
  274. 00:11:50
    I would highly recommend that people
  275. 00:11:51
    stay away from long acting or agents
  276. 00:11:54
    that are not easy to titrate. Even some
  277. 00:11:57
    IV agents, you know, like libetalol,
  278. 00:12:00
    it's not easy to titrate IV hydrolysine.
  279. 00:12:04
    You could potentially get away with like
  280. 00:12:06
    one or two doses initially before your
  281. 00:12:08
    infusion is there, but it's not really
  282. 00:12:11
    your ultimate blood pressure medication
  283. 00:12:14
    to use And lastly, I think when it
  284. 00:12:18
    comes to blood pressure, you know, the
  285. 00:12:19
    guidelines really focused on minimizing
  286. 00:12:21
    blood pressure variability. So more
  287. 00:12:23
    than really what goal to target, just
  288. 00:12:26
    avoiding these fluctuations is our
  289. 00:12:29
    ultimate goal with the idea that every
  290. 00:12:31
    patient should have their own specific
  291. 00:12:33
    individualized goal
  292. 00:12:44
    As far as anti-seizure medications for
  293. 00:12:46
    seizure perphylaxis, I think previously,
  294. 00:12:50
    a lot of people focused on seven days
  295. 00:12:54
    for seizure perphylaxis or maybe until
  296. 00:12:57
    your aneurysm is secured. But then
  297. 00:13:00
    there was more evidence after that kind
  298. 00:13:02
    of statement that we don't really have
  299. 00:13:04
    enough information or evidence to back
  300. 00:13:06
    that up So maybe that was just something
  301. 00:13:09
    that was recommended without much
  302. 00:13:11
    evidence behind it. The new guidelines,
  303. 00:13:14
    I think, really are focusing on who is
  304. 00:13:18
    at risk and targeting those patients.
  305. 00:13:21
    And I really like how they specifically
  306. 00:13:24
    said, you know, patients who have MCA
  307. 00:13:28
    aneurysm patients who have high grade
  308. 00:13:30
    and yours most of our hemorrhage,
  309. 00:13:32
    meaning hunting has a gradient in three
  310. 00:13:34
    or fissure, a gradient in three or four,
  311. 00:13:37
    people at cortical infarction, people
  312. 00:13:39
    at hydrocephalus, just like you
  313. 00:13:40
    mentioned, that they're at high risk of
  314. 00:13:41
    just worse outcomes in general. Maybe
  315. 00:13:44
    those patients should receive it.
  316. 00:13:47
    They do talk about the fact that we
  317. 00:13:49
    don't know what agent to use, but stay
  318. 00:13:52
    away from fenetoyne because we know that
  319. 00:13:54
    fenetoyne is associated with worse
  320. 00:13:56
    outcomes. Another additional purl is
  321. 00:14:00
    that fenetoyne will interact with
  322. 00:14:02
    namotapine and it will drop the
  323. 00:14:03
    concentration of namotapine, which you
  324. 00:14:05
    do not want that. So there's a lot of
  325. 00:14:07
    reasons really not to do fenetoyne
  326. 00:14:10
    Love-a-tracetam is a good option. If
  327. 00:14:12
    you don't want to do that, I think
  328. 00:14:14
    lecosamide could be another good
  329. 00:14:15
    alternative, which is a newer drug, a
  330. 00:14:17
    minimized drug-drug interactions and
  331. 00:14:19
    things like that. And then there's
  332. 00:14:20
    always this question of, okay, I have
  333. 00:14:23
    this really high-risk patient with
  334. 00:14:24
    hydrocephalus, you know, hunting has
  335. 00:14:26
    to bore. How long should I keep this
  336. 00:14:29
    anti-seizure medication for prophylaxis?
  337. 00:14:33
    The real answer is that we don't know,
  338. 00:14:35
    but the guidelines say that, you know,
  339. 00:14:39
    They kind of talked about studies
  340. 00:14:40
    looking at. three days or less, and
  341. 00:14:43
    three days and more, and guess what?
  342. 00:14:45
    The outcomes for preventing seizures in
  343. 00:14:48
    the hospital was the same, but people
  344. 00:14:50
    who received it for a longer duration
  345. 00:14:52
    actually had worse clinical outcomes at
  346. 00:14:54
    the end in long term. So I think
  347. 00:14:58
    there's still probably
  348. 00:15:01
    more, I don't
  349. 00:15:05
    want to say evidence, but probably it
  350. 00:15:06
    looks like it's more favorable to use
  351. 00:15:10
    the shorter duration of seizure
  352. 00:15:12
    prophylaxis, but the actual true
  353. 00:15:15
    duration of seizure prophylaxis is not
  354. 00:15:19
    exactly or 100 known
  355. 00:15:32
    Absolutely, so just to emphasize, we
  356. 00:15:34
    don't have an exact target for blood
  357. 00:15:36
    pressure. We want smooth lowering of
  358. 00:15:39
    the blood pressure in our patients who
  359. 00:15:40
    are not secured. Using those titratable
  360. 00:15:44
    agents, again, we know hypotension is
  361. 00:15:46
    bad for our patients. And then there's
  362. 00:15:49
    still a lot of equipos about how long to
  363. 00:15:51
    treat with seizures, but certainly
  364. 00:15:52
    avoiding Benitoin and then trying to get
  365. 00:15:55
    away with the least amount of seizure
  366. 00:15:57
    medication possible I think what I
  367. 00:15:59
    really liked about these guidelines is
  368. 00:16:01
    that they really try to emphasize, look
  369. 00:16:04
    at the patient in front of you. The
  370. 00:16:05
    grade one subarach probably does not
  371. 00:16:07
    need to be on a whole week of seizure
  372. 00:16:09
    prophylaxis. However, the high grade
  373. 00:16:12
    patient who you don't have a great exam
  374. 00:16:14
    for and you're maybe seeing that they've
  375. 00:16:16
    got some IIC variability, they're being
  376. 00:16:20
    monitored, that patient maybe is a
  377. 00:16:23
    totally different patient than the low
  378. 00:16:25
    grade subarach The other thing that was
  379. 00:16:28
    different from these guidelines T-X-A.
  380. 00:16:31
    So Salia, walk us through, like what
  381. 00:16:33
    happened with T-X-A?
  382. 00:16:36
    Absolutely. As I said, this is a
  383. 00:16:38
    change. So previously, I think there
  384. 00:16:41
    was a lot of maybe interest and
  385. 00:16:43
    guidelines made it sound like previous
  386. 00:16:45
    guidelines, made it sound like it's
  387. 00:16:47
    reasonable to give T-X-A, you know, to
  388. 00:16:49
    prevent re-bleeding, especially if
  389. 00:16:51
    you're going to be an institution that
  390. 00:16:52
    you can't treat that, you know, and
  391. 00:16:54
    you're as small as they age immediately
  392. 00:16:58
    And I think one trial came out that made
  393. 00:17:01
    this really
  394. 00:17:05
    made this new recommendation. And then
  395. 00:17:07
    even after the guidelines got published,
  396. 00:17:09
    there is another study that was
  397. 00:17:10
    published in Brazil that I'm going to
  398. 00:17:11
    talk about that. Also, I think make
  399. 00:17:13
    things even easier to and more clear to
  400. 00:17:16
    understand. So the ultra trial came out
  401. 00:17:19
    and they showed that if you actually
  402. 00:17:22
    treated that aneurysm with an average
  403. 00:17:26
    time of 14 hours, giving
  404. 00:17:29
    anti-pharmalytic such as TXA did not
  405. 00:17:31
    help with outcomes. But then they kind
  406. 00:17:33
    of put it out there that, okay, like
  407. 00:17:36
    if you're in an institution that you
  408. 00:17:37
    can't act on it immediately, meaning
  409. 00:17:39
    you can't treat this aneurysm
  410. 00:17:41
    immediately, maybe there's a role. But
  411. 00:17:43
    then may of this year in Brazil, there
  412. 00:17:45
    was a study that was published and they
  413. 00:17:47
    showed that even in centers that they're
  414. 00:17:49
    not treating their aneurysms quickly, I
  415. 00:17:52
    think the average time for, you know,
  416. 00:17:54
    neuroi or procedures is about three to
  417. 00:17:56
    four days, which is pretty late. They
  418. 00:17:59
    also not only showed that this was not
  419. 00:18:02
    better, there was higher mortality with
  420. 00:18:03
    TxA. So I think right now the new
  421. 00:18:07
    guidelines are saying, we do not
  422. 00:18:09
    recommend this. So I think TxA is out.
  423. 00:18:13
    So I think that's just something that is
  424. 00:18:15
    different. And obviously it's not
  425. 00:18:18
    benign, there's just a sort of
  426. 00:18:20
    thrombosis, there's all these other
  427. 00:18:21
    conditions that can happen with Tx and
  428. 00:18:23
    other agents in that category, in that
  429. 00:18:25
    class, which is, I mean, a cup of
  430. 00:18:26
    garlic acid.
  431. 00:18:29
    just reinforcing the guideline
  432. 00:18:30
    recommendation that
  433. 00:18:33
    there is no real benefit for giving
  434. 00:18:36
    these agents. I love that. We're just
  435. 00:18:38
    moving towards being like, is
  436. 00:18:40
    intensivist. So I think we've kind of
  437. 00:18:43
    covered everything. I mean, really
  438. 00:18:45
    when a patient comes in, you have a
  439. 00:18:46
    high level of suspicion where it's
  440. 00:18:47
    headache of life, needs a head CT. It
  441. 00:18:51
    can be pretty confident within six hours
  442. 00:18:53
    of ICTIS that if the head CT is negative
  443. 00:18:56
    and you have a good scanner and a
  444. 00:18:58
    neuro-radiology reading it, you're good.
  445. 00:19:00
    Otherwise, you need to go down a
  446. 00:19:02
    diagnostic algorithm to make sure you're
  447. 00:19:04
    not missing it and that really does
  448. 00:19:06
    include the LP. We're thinking about
  449. 00:19:08
    treatment of, or first of all, triage
  450. 00:19:10
    to an appropriate center and really
  451. 00:19:13
    using medication wisely to prevent re -
  452. 00:19:17
    rupture to treat and prophylaxis against
  453. 00:19:21
    seizures and then to get somewhere to a
  454. 00:19:23
    place where they can get an EVD, but
  455. 00:19:25
    TXA, not so much part of the guidelines.
  456. 00:19:29
    This is a really, really fun part one.
  457. 00:19:32
    And then I hope you'll stick around. In
  458. 00:19:35
    the next episode, we're gonna cover
  459. 00:19:36
    sort of what do you do in these very
  460. 00:19:39
    complicated and super interesting
  461. 00:19:41
    patients land in the neuro ICU? Saw you
  462. 00:19:44
    any last words? No, I think you
  463. 00:19:47
    covered it all. We'll see you in the
  464. 00:19:49
    next episode. All right,
  465. 00:19:52
    bye.