This on-demand teaching session is focused on foundational knowledge for medical professionals in neurocritical care, with expert Doctor Available. The session will aim to cover key concepts related to aneurysmal subarachnoid hemorrhages, management strategies, medications for urgent hypertension, and the lengths of stays for both aneurysmal subarachnoid hemorrhages and perihemorrhagic cephalic hemorrhage in the ICU. This session will be beneficial for medical professionals of any experience level, and enhance their knowledge of critical care medicine.
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Dr. Bilal Butt, a neuro-critical care physician, joins us to discuss the diagnosis and management of aneurysmal subarachnoid hemorrhages. Learn common presenting features and complications that may arise during hospitalization.

You can reach Dr. Butt by email at:  bilal.butt@som.umaryland.edu

University of Maryland Website: https://www.medschool.umaryland.edu/profiles/Butt-Bilal/

Find me on Twitter @DrKentris or send me an email at theneurotransmitterspodcast@gmail.com


The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Learning objectives

Learning Objectives: 1. Explain when to be concerned about an intracranial hemorrhage. 2. Highlight the differentials for a thunderclap headache. 3. Describe the immediate treatment for patients who present with subarachnoid hemorrhage. 4. Explain the management of hypertension in a clinical setting. 5. Outline the typical duration of care for an aneurysmal subarachnoid hemorrhage in an ICU setting.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everybody. Welcome to the neuro transmitters, a podcast about everything related to clinical neurology with the goal of reducing your neur a phobia. I'm joined today by doctor available, but uh from the University of Maryland and he's going to be helping us out with some neuro critical care issues today. Thank you so much for joining us. Oh, thank you. Thank you for having me. I really appreciate. It would be a pleasure to be here. We were talking online earlier, you mentioned uh talking a little bit about aneurysmal subarachnoid hemorrhages. So when should we initially be concerned about more broadly, like like an intracranial hemorrhage? Absolutely. It's a very good question. And I think the first thing when we think of aneurysm or aneurysmal subarachnoid hemorrhage is this buzzword, thunderclap headache or the worst headache of your life? And um we've all read it in our review books. Um and we all see it too in practice. In fact, I just saw one recently and they literally tell you it's the worst headache of their life and, and, and, and by definition, a thunderclap headache is a headache that comes on very quickly, matter of seconds a minute and reaches its peak very quickly. And uh the differentials for that are somewhat limited and the top differential being aneurysmal subarachnoid hemorrhage. Gotcha. When we say, you know, obviously, you know, these folks, they often tend to present to the emergency department pretty urgently. Now, let's say they get that headache, you get the CT Scan and it shows no blood. Uh what, what are your next steps as far as that goes? I know the sensitivity of A CT is pretty high but it's not 100%. So what guys, your clinical decision making at that point with a negative CT head? Very, very good, very good thought. And, and if, if the differential of aneurysm, a subarachnoid hemorrhage is there and your CT is negative and your suspicion is still high. Um I think as neurologist, we are trained to, to find any blood in the brain that's not visible on the CT and, and the way we do that is, is grabbing some spinal fluid and, and looking for santa chromium to, and we have to be very careful because a lot of times these patient's are in the er, and we have to make sure that, that, that the lumbar puncture as best as possible as non traumatic. So we can find this um hidden aneurysm if you will hemorrhage and through xanthochromia, um spinning the blood and seeing if we can find any evidence that there's some hemorrhage. And obviously, if there's a suspicion we also look for imaging is in the form of TT A or an anti four vessel angiogram and, and sleeping a financial is um there. But, but to answer your question, I think I love our puncture is, is key in this. And I've seen this in my practice where um CT has been negative and you ideally want to wait six hours or so before or after the onset of the headache to look for xanthochromia as they can sometimes take time to show up in the CSF, right, the evolution of the blood product degradation, that sort of thing. Absolutely. Now, now this is, I'm gonna throw a little wrinkle in there. Now, let's say we've got, you know, we've got our CT that doesn't show any blood. We got a story that sounds like a thunderclap headache, maybe subarachnoid. And then we've got a CT A with, you know, like a say 56 millimeter aneurysm. Would you still pursue the CSF testing at that point in time? I mean, with the story otherwise hanging together quite well. Um because I know sometimes that can be a hard sell to some people because even if there is no blood, some people might still consider that the quote unquote sentinel headache um and treat the aneurysm regardless. So I'm just curious, how would that change in your practice? That's a very good question. And, and, and the good dilemma. Um now, like you said, Yeah, I mean, it could be a sentinel headache and not, and not necessarily sentinel headache doesn't necessarily mean the aneurysm rupture. It could just be that the aneurysm, um, is this expanding in size or morphology? Um, and that necessarily would not show up as blood in the CSF and, and if you have no other suspicion or other diagnosis, um, and you're left with that aneurysm hanging in there uh with no other explanation for the headache, especially thunderclap headache. I think more than not it would end up being treated. Gotcha. Gotcha. No, I think that makes sense. I, I can't think of too many people who would be so conservative as to, uh, just like, let's just watch it for a little while. Right. Absolutely. Uh, but let's, let's, let's go back into the more traditional course. So let's say we've got a little bit of uh subarachnoid blood on the CT. Um, what, what tends to happen next with the patient's? Where do we go from there with their management? Well, I mean, for one, this is one of the more common ideologies in neurology that as far as subarachnoid we see in the neuro ICU and so they all end up in a neuro ICU somewhere, hopefully. And, but the immediate treatment for these patient's happens in the, er, and it involves around controlling their BP which can increase the risk of rerupture, it reversing any blood thinners if there are any blood thinners. The traditional, obviously start with A B CS and the idea is to, to see if we can find that aneurysm and get it treated as quickly as possible. Now, there are ways to around it if, if you're not in a main center or if you don't have access to somebody who can treat the aneurysm. There are ways as far as giving them medications such as Amicar or TX A and, and kind of thickening the blood if you will and getting them to the nearest uh and the vascular center. Um and some people argue with giving seizure medicines for seizure prophylaxis, uh a controversy. Um and sometimes they need to be assessed for extraventricular drain as well based on the neurological examination and their CT Scan. And so that's uh immediate uh treatment and there are other treatments as well that tend to be a little more after uh er visit. So, so let's say, let's say we have someone who's, you know, markedly hypertension, you know, systolic in the one eighties to two hundreds. Um What's, what's your preferred medication for kind of bringing that down in a relatively urgent fashion? I think most um places uh use anything between niCARdipine uh prex calcium channel blockers essentially in or even labetalol is, is used, but usually they end up on a drip if the BP is really high. Um And if there's a component of pain, uh as far as the BP being high because of pain, then treating the pain obviously is very important as well. But usually I think the card opinion to answer your question is probably the most preferred agent. And I know at least when I've spoken to, er, doctor in the past part of their concern is that, uh, it's not as immediately available because, you know, you got to mix it in the pharmacy. It has to, the bag has to be prepped. And so I know a lot of your docs are reaching for labetalol initially. And I know that that's, you know, obviously, uh we're a little more biased because they're taking care of folks once they get on to the inpatient side. Um but uh the studies do tend to show that the BP variability tends to be associated with potential worsening outcomes as opposed to a more, even if it is mildly more elevated um with a more stable BP as that kind of mirrored your own personal experience as well. Um Yeah, I mean, I would say I would uh I would agree with you. Um And, and it can be hard sometimes really. Um and the acute phase controlling that BP as well. Uh But I agree, I mean, BP variability can be a predictor and in outcomes like you mentioned. And I know, well, I shouldn't say I know I've been anecdotally told that uh hydrALAZINE is a little less favored in, in most neuro critical care cases. Uh, is that correct? Like, just due to, like, I CPS and things like that? Yeah, I mean, I'll put it this way. Um, in one center I worked at hydrALAZINE was a big know and the other center I worked at hydrALAZINE was okay. Um, I don't know if there's a general consensus, to be honest is if you should avoid it altogether, but I agree with you. Uh, like where I'm at, where I had, where had been hydrology was, was something that was, was not the first line if you will and tended to be avoided. Gotcha. And I think it is play more consistent to say that nitro drips are generally very much frowned upon with intracranial pathology. I have yet to see one on board and I put that right. Yeah, I know, you know, the, the ICP uh intracranial pressure issues are always a concern uh more immediately to the forefront of, I think most neuro critical care thinking. But so let's say we've got someone who's coming in, you know, they've been stabilized, they're getting admit to the neuro ICU, they're undergoing all of their, you know, catheter based angiography, all that looking for the aneurysm, let's say aneurysms found they secure it. How long do these patients need to stay in the ICU? I mean, obviously, it depends a little bit on how, how severe their case is, but what would kind of be your, your guiding philosophy as far as who stays in the ICU, who can be downgraded to maybe like, you know, an intermediate full or things like that. That's a good question. Uh, and, and families asked us all the time and, uh, and unfortunately if it is an aneurysm or hemorrhage, they by themselves, usually 14 days in the ICU. Uh, and regardless of how good they're looking, usually they end up staying for good 14 days. Uh And the reason for that is um uh sometimes uh you know, can get complications. A lot of complications happens with these patients in ICU. And the biggest one we're concerned about is a delayed cerebral ischemia or symptomatic based as um and it can happen up to 14 days or even beyond, I've been up to 21 days, but usually like to watch them for 14 days. Now, there is an entity called perry minute cephalic uh hemorrhage, which, which kind of sometimes looks similar to aneurysmal subarachnoid hemorrhage. With the exception, we don't find an aneurysm and those cases. Uh you know, personally, I would uh have them out of ICU if everything is looking good and, and our suspicion is for parents to feel like I would have them out in a week or so. But a true aneurysmal subarachnoid hemorrhage. Uh Unfortunately, I mean, and it's, you know, quite a bit of a challenge with the families when they see their loved ones doing so well. Still nice to you for 14 days. But that's some what has become a protocol uh unfortunately, but the ones that are not doing so well, uh you know, families can understand why they're in ICU. Yeah. Now, you know, you mentioned uh this is a great point. I was hoping you would bring this up, right? Delayed cerebral ischemia or DC. I uh I would almost say formerly known as vasospasm. Um for those who might not be familiar, how would you define that from a clinical perspective? So, from a clinical perspective, it basically is a drop in your GCS of two points or more a change of your NIH scale exam um or focal neurological deficit if you will um usually lasts for about an hour or so uh in the setting of this aneurysmal subarachnoid hemorrhage. And, and so clinically, that's definition um is when we have a change in or decline in neurological examination. And we attribute this to what you like you mentioned DC I and then uh if that is our suspicion and then we go ahead and treat DC I and unfortunately, you know, uh we have, unfortunately, it's a rather we have some good treatments and there is more on the horizon and but if, if, if the CIA is your suspicion, uh usually they end up in the past, we used to do what's called triple H therapy hypertension. Yeah, he made him a dilution that's kind of falling out of favor. Uh I keep seeing it referenced in uh in critical care papers is like formally, yeah, I trained in it. I used, I trained in it. Uh so it wasn't too long ago and uh but now it's mostly hypertension drive, the blood pressure's up and get them um to catheter angiogram and see if we can inject uh blockers or mildew known um uh verapamil things like that to help open up those vessels. And um we also using the motor pain, which, which helps with delayed, stable escaping as well and outcomes. And I've seen it even, even severe cases, they might even do like partial balloon, angioplasty on some vessels. Has that been something you see, I know that's very center dependent. Yeah. Honestly, I've personally not seen it, but can it happen? Absolutely. I think the preferred method initially is to try to inject um the drugs if you want to uh to open up those vessels. And this is, again, it's a temporary effects. Sometimes you need to go back multiple times um to, to keep injecting these drugs. Um And our goal is to prevent the worst thing in DC I can do is all strokes and worst outcomes. And I've seen that happen unfortunately, where they go back and unless end up having strokes. Yeah, it's, it's really terrible because, you know, otherwise a lot of people with subarachnoid do recover quite amazingly. I've seen cases where believe it or not, patients come in and gift of hope was called and, and the next thing, you know, they're walking out of ICU, uh, I've seen cases where they looked very, very, uh, sick and, and, and, and didn't expect anybody to be walking in the clinic and talking to you. And, um, so, yeah, I mean, in the acute phase, like I tell, patient's, it's, it's, uh, if they're really sick, it's not about recoveries about getting them through this critical first two weeks and then the recovery phase happens. And, but yeah, absolutely. They, I mean, for how bad they look and then initially they can look really good, the ones that make it right. Yeah, I know, I still, you know, you know, just a little anecdote when I was a resident, we did about 56 months of neuro ICU and there was this, you know, sweet little lady. Uh she was, she was in the ICU for, you know, just about my entire rotation that month. And uh like, uh I think it was a couple of years later. I wasn't even at the program any longer, but I got a card in the mail and it was her standing up like waving at the camera. Uh and, you know, she said, I don't know how she got my cell phone number, but she, she texted me like the next year on the anniversary of like, hey, I'm doing great. I'm out driving around in the community. Thanks so much problem. And, you know, it just, it really does, you know, make everything that you're all this work that you're doing really worthwhile. Uh to know that yes, those people out there, uh some of them do make it through, they get back to a normal life if you can get them through that initial really high acuity period. And I know it's, it's always great to hear stories like that. Absolutely. No. So to that point, who are, who are these patient's obviously, you know, there are some different scoring systems that we use on, on admission to help kind of risk stratify these patient's. So who are the highest risk patient's for things like DC, I, what kind of things do we do to prevent it and so forth? So, as far as uh DC I um uh is concerned, um uh before I go to DC I, but, you know, the scoring systems we have, usually we use what we call is the hunt and hess, we have a fissure modified Fisher scale. And uh and then we also have the World Neurological Federation in society score. Um And all of these scores essentially tell you one of them tells you about higher the score, the higher the mortality, the one of them tells you the higher the score, the more likely, um, you'll tend to have a basal spasm. Um Now essentially tells you the worst that come looking into you, the higher likelihood they'll have mortality the worst. The scan looks as far as hemorrhage in the ventricles, thick blood, more likely they're going to have uh video spasm and what we can do um to, to treat this or prevent this is one is basic things. Um, preventing are fevers is one thing is what we do. Nice. You have any fevers helps uh, with preventing DC I keeping the blood pressures auto regulated. So we don't, once the aneurysm secured, we don't tend to be aggressive, lowering the blood pressure's allow that profusion. Other things we do is in the motor penis. Something that everybody gets has been studied in a British trial, multi central British niMODipine aneurysm trial, which showed the niMODipine actually. Now, although it didn't reduce the vasospasm but helped in better outcomes. Um and we presume the better outcomes was because it helped treat DC I and other ways other than vasospasm. And then looking at the sodium, for instance, a lot of these patient's have hyponatremia, which can also be a risk factor for DC I. So we make sure the sodium is adequate and, and we look for causes hyponatremia, which more common one SIDH or three, both salt wasting and treat it accordingly. So it's just some of the ways we prevent DC I and the way we treat it is is what we discussed earlier, but we can prevent it. That would be uh ideal, right? And I know there's a couple, you know, some people talk about like transcranial Doppler trends or in some of the really big uh like quaternary centers, we also have like continuous eeg looking at like alpha delta ratios and things like that. Uh Which one do you tend to use more? Uh what uh what tends to be more available slash reliable in your experience? Yeah. So I think the more data we have the better um and at Maryland, we use belts. So the patient's that we think are high risk for DC I, they all end up getting transcranial dopplers and the transcript Doppler is usually the middle cerebral arteries, the most reliable numbers we get. Um and the trend is very important, like you said, um and we look at the alpha delta ratio looking how high or low it is and can predict uh DC I even, you know, three days or more prior to even happening. Um So if you, all these patients have EKGs, we look at their uh doctor ratio, we um look at tcds, look at their velocities um and make a judgment based on that. But again, like you said, um uh there are multiple ways to do it and, and uh tcds with normal velocity doesn't necessarily mean that that DC I is not happening. Um So it's uh which is why I wouldn't rely just on one test uh to make the call. It's a clinical judgment with all the information put together. So, yeah, I mean, cause there's certainly plenty of places in the country where they may not have like transcranial dopplers or, you know, continuous eeg it uh it becomes one of those things. So if, if all you have is your clinical exam, let's say in, you know, a non neuro ICU should those patient's like, what can those patients' be treated optimally? Uh when all you have is your clinical exam to rely on. I guess that would be the question I would, I would put to you. Um Well, it optimally, ideally you would want as much information as possible. Um And even a CT a CT profusion is something we use uh to look for um uh for delay tissue ischemia. And the counter argument could be that you do all these tests and they're normal but your suspicion is high for the later Sedloski me a because of the exam. Then I agree with you that regardless of all these tests are telling you when your suspicion is high because of the exam, then they should be treated and, and that's how we treat them and I've done them based just on the exam and regardless of everything else being normal. And I, I think to your point clinical exam, uh and your clinical judgment and suspicion proceeds all these other tests if, if, if they're negative. So, and you do it based solely on exam. Absolutely. Yeah. Yeah, it's nice and everything lines up and your data is all concordant. But yeah, sometimes just to like, just doesn't, it doesn't look right, it doesn't feel right. You know, you get that clinical intuition just rattles around in the back of your mind. So 11 thing you mentioned earlier, um and I, I'm familiar with a little bit of this controversy in terms of prophylactic anti seizure medication uh in your own clinical practice. How do you tend to approach that and say someone who has not had a seizure and is still under, you know, you know, it's kind of in that little gap of maybe 12 to 24 hours where they haven't yet undergone like a catheter angiogram. So, yeah, I think, like you said, it's a little bit of variable and I think you ask a few different uh neurologists will give you different answers and I'm not sure what, what your preference is, but the way I uh personally do it is until the aneurysm secure there on prophylactic seizure medications and usually end up staying on it for about seven days before it stopped. Now, obviously it's different if they've had seizures, but I tend to have them on uh uh decision medications at least for the first seven days, um, while the aneurysm secured and after that, it's, it's stopped unless there's a reason not to stop it. And yeah, I, I would tend to, uh, do that same thing in my own practice as well. Um, now I know the tricky bit is always, if, if they haven't had a seizure and no aneurysm is found on imaging. How do you still, like? I would still tend to, at least in my practice. Do you usually kind of treat, like, almost like an acute symptomatic type event to do the seven days? Like, you would almost be like a neurosurgical type patient. Yeah. Yeah, I, I agree with you. And, and if you don't find aneurysm and, and you think it's maybe Paramount cephalic, uh, and in seven days they get repeat imaging and, and it's negative then, then, yeah, I, I stop it and, you know, and there's a lot of controversy even with just inter practical hemorrhage and seizure medication and in this New York styles. So it's, I think it's a gray zone right now but, but I'm sure other people have other thoughts but, but personally, uh, I don't keep it unless they've had seizures. I tend to lean the same way. I know. So, uh, I, I have definitely come across the neurosurgeons who do put it on for intraparenchymal hemorrhages. And I'm kind of like, okay, kind of shrug my shoulders and, like, you know, it's fine, I suppose, you know, a week isn't gonna probably make a big difference. But, uh, I probably wouldn't do it, but I, I tend to be a little bit of a purist as far as that aspect of things go. Exactly. No, I'm with you on that and I mean, it would be a lot of patients ending up in your clinic with the seizure medications that never had seizures. And now the question you as to how long they need it and how to get off of it, went to get off of it, um, to be fair, that already happens. Uh, but I mean, it's, it's good to, uh, to work those folks up to get the right diagnosis eventually. Um, Now, now you brought up a great another great point. Uh These perry mesencephalic subarachnoid hemorrhage is for those who aren't familiar uh kind of where are they, why do they happen? And how does that change our management when we see that pattern of blood versus different patterns? So, a pyramid cephalic by definition is usually around your midbrain a little bit around your Ambien cisterns, which is the CFCs of space around the mid brain. Um Usually not in the inter hemispheric fishers, although it can be a little bit of their um rarely causes hydrocephalus, although can cause hydrocephalus as well. Um And ideologies for that is deemed to be unclear but thought to be from either some venous hemorrhage or some small RTL perforator. Um And the work up essentially is the same as an aneurysm, a subarachnoid hemorrhage, although we find no aneurysm and the treatment um also mirrors the treatment of aneurysm, a subarachnoid hemorrhage. Although their risk of hydrocephalus Delatestryl ischemia uh is much less and their outcomes are much better as well. Um, and most of them can, you know, have good outcomes and for the most part, the bleeding hemorrhage doesn't recur. Um, and, um, yeah, but for the most part, um the work up is the same and we also look for, um, sometimes a spinal A VM that might have caused a hemorrhage and we're not finding an aneurysm and we look for other ideologies, a micro A VM in the brain stem, spinal A VM. Uh and other, a lot of other reasons uh for an irritable subarachnoid hemorrhage. We got to make sure there's no mycotic aneurysm which are small distal aneurysms from infection, um uh are chilled dissections. Um but usually these are all ruled out and for the most part, we end up finding nothing and, and, and believe it or not, these patient's look good coming in, they look great leaving and, and they usually have no issue that's good. And now you mentioned another fortunately somewhat common complication with subarachnoid hemorrhages, hydrocephalus. At what point does that one? I know, you know, obviously we kind of monitor again, clinical exam looking for like serial scans, things like that for evolution. What kind of thing should people be watching out for? If someone starting to show some sort of clinical or radiologic decline, that was like, I need to get the neurosurgeon on the phone. Yeah. So it's um very center dependent. Some are very aggressive with the drains some are wait for clinical decline. Um And I personally uh of the opinion that if you have a clinical suspicion, radiographic a while, radiographically it fits, then absolutely, these people need drains because without drains, they can decline very quickly and, and even end up dying with the elevated intermingle pressures. Um uh And the biggest thing we look for is obviously is, you know, if there's nausea, vomiting, uh if there's a decline uh in the neurological examination, when they're more sleepy could be more agitated even. Um And the images fit where you see hydrocephalus. Um and there's blood in the fourth ventricle, you have a high suspicion, the hydro self has been worsen, then a drain is very appropriate. Um And then, then it becomes a bit more tricky if the drain is put in before the aneurysm secured. Uh But after the aneurysm secured, uh and there is suspicion these uh patient, all I think you should get a drain because uh you know, without a drain and if they worsen and that's missed, they can end up dying. Um uh But obviously the drain also has its complications. Uh you know, you can have to kind of weigh the both. But um I'm the personal opinion that clinically should be followed, fit with imaging. And if there is a suspicion, a drain absolutely is, is necessary. And I think for the most part in large academic centers, um they all end up getting drains if, if needed and and if they don't need it there, watched closely nice of you. And you know what I was always taught as a resident was that when you have very, very early hydrocephalus, the first place to look was like the uh inferior horns of the lateral ventricles kind of in the temporal lobes. There is that in your experience as well with uh we look at the temporal horns, that's the first place like you mentioned to looking for early hydrocephalus and uh it can progress and involve more than is the temporal horns. But I agree. Absolutely. Like you said, uh let's the one place we look for initially for hydrocephalus and it becomes a little tricky if they have executed allocation and uh but absolutely 100% true. So as as people get towards the the end of their 14, so let's assume that things have been going well, they didn't need a drain, the aneurysm secured, the blood is slowly resolving on repeat scans where patient's usually heading or is it? I assume you're going to be very dependent on their level of function kind of near the end of that two week mark. Yep. So, I mean, it's a mixed bag and in two weeks, if they're looking good, uh I've had cases where they end up on the floor, general neurology floor and they go home, there's also cases where they go to rehab because of some focal deficit such as weakness and requires a little bit of rehab. Uh There are also cases where unfortunately they weren't able to be excavated and they had a tracheostomy put in and, and they end up also in rehab and that can support a tracheostomy and plus minus feeding tube. And there's also cases where you do the best you can and, and neurologically, they worsened, they become close to brain death and, and then you have to have a family discussion about goals of care. Um But like you said, it depends on their functional status, but our goal is, is to get them to the floor and eventually we have uh and then follow them up in, in clinic to see how they're doing because a lot of these patient's have memory issues, neuro cognitive issues and so still need to be followed up. Absolutely about what again, you know, and in your estimation, uh in terms of mortality at time of discharge from the ICU, what, what numbers are we usually looking at? So, I mean, it's, um uh I guess you could say maybe the one third, one third, uh you know, mortality. Uh and well, I mean, a lot of times patients don't even make it to us. And, and uh and uh you know, we're essentially excluding those cases as well. Uh So it is, you know, it is a uh entity of, of high mortality if you will. But now that if we can get to them quickly and treat them. Um, there's a lot of ways we can change that, uh, in a lot more ways that we're finding out that we can help these particular set of disease. Yeah. No, I, I think that's, that, that's absolutely right. You know, if we, if we are able to get them over that, that hyperacute period, um, there's, there's a good chance, uh, that these people could have a really good outcome uh neurologically. Absolutely. So, you know, kind of going back a little bit. Um There's a few things that can present similar to supper at night temperatures that might sometimes muddy the waters a little bit. Uh One entity, you know, let's say if we changed our vignette a little bit, let's say that, you know, someone has had repeated worse headaches of their life, uh sometimes associated with like sexual activity, things like that for all neurology residents out there listening. That's going to like immediately trigger the board question for like reversible cerebral vasoconstriction syndrome or are CVS, does that differ in your work up at all? Like if, if say you have someone who has these episodes or do you pretty much run them through a very similar diagnostic algorithm? Yeah. So, uh I mean, like you said, are CVS is part of the differential. Um the most common cause of subarachnoid hemorrhages trauma and, and uh we, you know, um treat those differently although they can have complications of symptomatic basis spasm, but they're treated a little bit differently. Um, but as far as our cvs, um, it's, it's, I mean, one, it's not that common. We read a lot about it but I only, I can only say I've only seen a handful of cases. But yeah, it is treated differently. It's not treated as aggressively as we do. The aneurysmal subarachnoid hemorrhage. I mean, it is treated with a calcium channel blocker. It's treated with a repeat angiogram in a few weeks just to make sure that vasospasm has resolved. If it's truly are CVS, it should resolve around 12 weeks or so, we should have resolution. And if you think it's our CVS, a lot of times it's based on what do you think the etiology is a lot of times they're on SSRI S and we try to avoid whatever we think the trigger is for, for the, our cvs. I mean, because there's really no aneurysm to treat, it's basically treating the cause if there is one and, and uh the calcium channel blocker with, with whatever effect that has and just hoping that enter the vasospasm resolves and their headache resolves and it's kind of um does that does the trick. But uh yeah, it's not, not so much of an aggressive work up that we do with aneurysmal subarachnoid gosh, uh as you said, right, uh we've been focusing mostly on aneurysmal subarachnoid hemorrhage. So, in terms of intracranial aneurysms who are the people who are considered to be at risk. Uh, let's say someone is worried, maybe I've got an aneurysm or I've got headaches. Uh, we don't want all of them coming in for CT CT s of their head. Uh, but who are the people who should have perhaps a little more concerned and maybe get that checked out by their physician? Yeah, it's, it's a good question because I'm sure neurologists in the clinic, um, see headaches all the time. And when would you be worried of aneurysm? It's a hard question to answer because, um, until you check for, you won't know. But some of the risk factors are BP, hypertension, uh, smoking, symptomatic drug use, cocaine amphetamines. And, uh, the Japanese finished populations is at a higher risk for aneurism. Aneurism. I mean, it's been reported as high as, I mean, 2 to 5% of the population and usually around the 2% mark. So, 2% of people, sometimes people die not even knowing they have aneurysms on autopsies. Um, and, and, and I think the big thing is if you've have family, history of aneurysm is also very important to, uh, take in mind if, especially if you have to first degree relatives. And, uh, I mean, if they've had an unreasonable rupture in the past and then coming in again, I, again, kind of the word raises suspicion. But, yeah, it's, it's a good question and, and, uh, it can be a little complicated to know, rule out unless they've been checked for it. Uh, it becomes a little complicated but I agree with you. It's, it's just impossible to start scanning everybody for aneurysms because it's just unrealistic. But nowadays we have treatment for aneurysms prior to rupture. And uh a lot of patients are developing or finding out to have aneurysms incidentally for instance, and those are getting treated and followed up on and, and the rupture uh for those patients', hopefully the risk is minimized because now they're getting treated one because it's that, that incidental or two because we're just doing more of these imaging and finding out more and more people uh with these aneurysms or uh other thing I should have mentioned is obviously a polycystic kidney disease and some genetic conditions like elders, downloads and things like that should all play a role in uh looking for aneurysms. Now, I know you're not an interventionalist per se, but I'm going to let you know, guess that in your practice you see more than a few aneurysms that are unwrap shirred. Uh, at what point do you think it like if you say a neurologist or even, you know, a primary care physician who has a patient, you have an incidental aneurysm. At what point do they really need to be seen an interventionalist to talk about? Maybe like having a coiling or some other type of procedure done? Yes, I think if you have an aneurysm. That incidental. A lot of it depends on the location and tear circulation versus post to your circulation. And the size and the morphology uh is a regular, does it have daughter sex? So I think the best thing to do for these patient's is to have them seen by endovascular neurologist who even if it aneurysm is not being treated, uh they're followed up with repeat imaging. And the thing as a neurologist we could do for these patient's is to limit the modify modifiable risk factors, uh smoking drugs, hypertension, the rest of it is the natural progression of the aneurysm. And if it qualifies for treatment, they end up getting treated. If not, they usually followed uh for increase in size or change in morphology. And if they have one aneurysm, there's almost about a 20% chance they have another aneurysm. So making sure we've located all the aneurysms and essentially kind of following it up uh follow up and then these aneurysms just, just to be clear, they happen normally at branch points uh which is very different from mycotic aneurysms which are uh distal arteries just to make sure we have the right kind of aneurysm which is a Sackler Berry aneurysm which can be different from other types of aneurysms. Yeah. Yeah. I know especially in, in like the, I see you as someone who might be like back to remake or septic from some other organism or maybe has a history of IV drug abuse, uh, those mycotic aneurysms in my experience, I've seen some pretty nasty clinical scenarios developed and I'm, I'm sure you have as well. Absolutely. Absolutely. I know every endovascular person that I've talked to about those in the past say, like coiling. I'm just always, well, I shouldn't say always, but for the majority of times does not work well and tends to cause more problems. Yeah, I, I agree with you is, I mean, I think we don't have enough, um, data to say what the right course is. I think the biggest thing is to treat the infection, which is the cause of these aneurysms. And hopefully, once that inflammation resolves, these aneurysms are very small usually and they kind of resolve and these are false aneurysm. So they usually hopefully resolve and you can follow up with repeat imaging. But yeah, there's no really good answer because although I agree with you, most of them don't get coiled. There's really not. We don't, I don't really know what the best approach of these is and I personally have not had any of them that were coiled and most of them were just followed with, with antibiotics. I know. And it's always challenging because, you know, especially if they do have a little subarachnoid and blood your hands just like itching. It's like I should be doing something which I know, you know, as a doctor is always one of those uh traps to fall into sometimes. Just got to not do something. Exactly. I agree with you. I said sometimes more is bad, less maybe better. Uh, that's always a good thing to check your own. Uh, what are my motivations here? Am I treated myself for the patient? Exactly. Absolutely. Very good point. Any other, uh, tips or pearls that you would offer for, for anyone who might be taking care of people with subarachnoid hemorrhages or aneurysms in general. Uh Well, I mean, it's uh interesting disease. It's, there's a lot of research in this area. A lot. Hopefully in the future, we'll have a lot more uh treatment options. There's a lot of treatment that I did as a resident that we're no longer doing for instances, the magnesium drip, the statins. Um, so a lot has changed in just a few years, uh, that I've been dealing uh with these patient's. But I think the best thing we can do is to prevent re bleeding in these cases and we know rebleeding carries a higher risk is to recognize these cases. I mean, they can be easily missed for migraine and uh missed for um arthritis, the flu. Um And so I think the best thing we can do is is think of it whenever we see patients with headaches and if our suspicion is high is to, to rule those out. Um, and as far as other pearls, I think a lot of it relies on early diagnosis most of the other pearls, I think our end up kind of more in the ICU realm and because there's a lot of other complications with these patient's, other than neurological, there's pulmonary, there's cardiac. So it's a very complex disease condition. Actually, that's a, that's a great point. Would you mind talking about the subarachnoid heart? I know that's, that's, uh, that's a topic that I don't think I hear enough about this might be a little selfish on my part. But our listeners indulge us. Yeah, I think, I mean, in the ICU, we see it quite a bit and uh it may be manifested with low BP and we think they're septic, but if they're not septic, they just have a high troponin EKG changes of ischemia. And unfortunately, this can look very similar to an M I and the only way to rule or to diagnose this and exclude this is with an echocardiogram and some vessel imaging and echocardiogram usually very straightforward has stress cardiomyopathy where um it is typical ballooning for instants, the ejection fraction can be low and the treatment is supportive. Um Now it's a scheme ick, the treatments very different and the ideologies or the pathophysiology behind that is basically the separate note hemorrhage inflammation, affecting hypothalamus, a lot of catecholamine surge, affecting the heart. And these cases can happen also coincide with with the CIA as well. So a lot of things can be happening to these patient's at the same time. And your choice of pressure that using these patient's to raise the BP. If it's low also depends on the echocardiogram features, whether it's Levophed or whether it's phenylephrin based on the echocardiogram features. But yeah, you can have stunned myocardium, Takotsubo's or it could just be, they had a poor heart and the stress caused them to have an M I um and uh a lot of, yeah, a lot of things and, and then if it's stress cardiomyopathy and repeat the echocardiogram down the line, uh that you can see the ejection fraction starts to recover, the heart starts to recover. And if it doesn't, you may be a little worried and want to do some more ischemic work up. Gotcha. So, so if there is that concern for like the rise and proponents and maybe some ischemic features on an EKG, do they normally get a heart cath while everything else is going on as well? Yeah, I mean, if we're suspicion is less towards Takotsubo's and more towards ischemia, heart cath is something they get but not necessarily acutely unless uh we think that they're having a stemi. Um just because of this dilemma of blood thinners and hep brand while they're in the bleeding phase. Um But yeah, so if they need it, they end up getting it but, but perhaps not acutely unless it's a stemi. Gotcha. Yeah, no one wants to put a stent in and not be able to put on anti platelets or heparin or something like that. Uh That's, that's always a dicey proposition. Well, that was great. I appreciate you coming on and talking with me about, about all these issues that can come up with subarachnoid. Uh If folks want to find you online, is there any where that they should be looking for you? Are you on Facebook, Twitter? Anything like that? Uh Not, not necessarily, I use those platforms a lot to be honest. Uh But if they need to get a hold of me, uh I'm on the University of Maryland website page and, and my email is there. I'm happy to respond to anybody that has any questions? Awesome. Thank you so much. I'll put a link to that in the show notes and thank you once again, I really appreciate it. I really appreciate you having me and uh thank you so much. Have a good weekend. You too. Take care. Thank you everyone for listening. If you enjoyed this podcast, please rate review and share it on Apple Spotify or wherever you get your podcasts and please subscribe for future episodes. You can reach me on Twitter at Doctor Ken Trees. That's Drkentris or by email at the Neuro Transmitters podcast at gmail dot com. With any questions or show suggestions. We'll see you all next time.