Question

Discuss medical management of patients with aneurysmal sub-arachnoid hemorrhage before and after coiling the aneurysm.

Hint:

The goal of medical management in aneurysmal sub-arachnoid hemorrhage is to prevent complications such as rebleeding and vasospasm while promoting recovery.

Answer 1

The medical management of patients with aneurysmal sub-arachnoid hemorrhage (SAH) before and after coiling involves various critical steps.
Step 1: Pre-Coiling Management:
1. Blood Pressure Control: Maintaining an optimal blood pressure is essential to reduce the risk of further bleeding and facilitate the aneurysm's coiling. Antihypertensive agents such as labetalol or nicardipine may be used.
2. Monitoring for Vasospasm: Close monitoring for signs of cerebral vasospasm, typically between days 3 and 14 post-SAH, is crucial. Agents such as nimodipine are used to prevent vasospasm.
3. Seizure Prophylaxis: Anticonvulsant medications like phenytoin may be given to prevent seizures following SAH.
4. Intensive Care Monitoring: Patients are often admitted to intensive care for continuous monitoring of neurological status, intracranial pressure, and fluid balance.
Step 2: Post-Coiling Management:
1. Monitoring for Rebleeding: After coiling, the patient is closely monitored for signs of rebleeding. A repeat CT scan may be conducted if rebleeding is suspected.
2. Preventing Vasospasm: The same preventive strategies for vasospasm as in pre-coiling continue post-coiling, often with continued nimodipine therapy.
3. Fluid and Electrolyte Balance: Careful monitoring and correction of electrolyte imbalances and fluid management are critical.
4. Neurological Rehabilitation: Rehabilitation may start early depending on the patient's neurological status post-coiling.