The nurse recovering a 65 year gentleman who underwent rt carotid endartectomy 2 hours ago calls you asking for a urgent review. The patient’s blood pressure is high 190/ 100 and he is complaining of a severe headache.
What is your management plan?
What are the Pre-Operative risks factors that can be identified in his history?
Can you illustrate your management algorithms?
4 Comments
Ahmed Nasr Mohammed Abdelfattah Ahmed Osman
the patient after carotid endarterectomy with very high bp and severe headache i have to think mainly of hyperperfusion syndrome or intracranial bleed
first thing i will do quick neuro exam and if any new deficit i will send urgent ct brain
at the same time i start controlling bp but carefully not too fast, i can use iv labetalol or gtn or nicardipine, target to bring systolic around 140
give simple analgesia for headache and admit to icu for close monitoring, if seizures appear i treat them
i will also inform vascular team and anesthesia immediately
preoperative risk factors are uncontrolled hypertension, contralateral carotid occlusion, recent stroke or tia, diabetes, old age, impaired autoregulation
algorithm is simple: neuro exam → ct if deficit → iv antihypertensive → gradual bp control → pain control → icu monitoring → treat seizures → inform team
This patient suffers hyperperfusion syndrome or ICH
the management would be supportive medical therapy including analgesics, mannitol, bp control with b blocker ccb and thiazides
urgent CT scan and carotid duplex
risk factors include uncontrolled HTN patients, patients on blood thinners
A1:
According to symptoms and timing ICH or HPS with cerebral oedema are most likely in this case
Ptn should be investigated TCD CT or MRI
Management after ABCD and O2 supply includes supportive ttt with analgesics mannitol steroids anti epilepsy anti HTN b blochers CCB dieuretics along with discontinuation of bl thinners
A2:
Pre op RF
age smoking dyslipidemia renal disease anti coagulation anti platelets poor control of HTN
a case of mostly post CEA hyper-perfusion syndrome vs intracranial hemorrhage
Management Plan :1- immediate ABC assessment: airway,breathing & circulation (IV access)
2- check neurological status : GCS
3- Monitor blood pressure: BP,ECG,O2 saturation
Target SBP= 100-140 mmHg
Use short acting anti hypertension drugs as Labetalol (B blocker ) / Nicardipine
4- Neurological Evaluation: Urgent CT brain to exclude intracranial hemorrhage or stroke
5- Supportive Care : Elevate head of bed 30 degree, Analgesic, ICU admission
Risk Factors:1- Uncontrolled preoperative hypertension.
2- Longstanding hypertension
3-Older age (65 y).
4-Diabetes, renal impairment.
5-Recent high-grade symptomatic stenosis (TIA/stroke).
6-Intraoperative cerebral ischemia or clamp intolerance.
7- Severe ipsilateral carotid stenosis (>90%).
8-Contralateral carotid occlusion or severe disease.
Alogorithm :Patient post-CEA with High BP (190/100) + Headache
│
▼
Assess ABC + Neuro status + Monitor BP
│
▼
Exclude surgical cause (bleeding, airway, pain, anxiety)
│
▼
Severe Hypertension with Headache/Deficit?
│
┌────────┴─────────┐
▼ ▼
Neurological deficit No deficit
│ │
Urgent CT Brain Control BP
(rule out ICH/Stroke) with IV Labetalol/Nicardipine
│
▼
ICH → Neurosurgery consult
Ischemia → Stroke team
Normal CT → Hyperperfusion syndrome
│
▼
Strict BP control + ICU monitoring
the patient after carotid endarterectomy with very high bp and severe headache i have to think mainly of hyperperfusion syndrome or intracranial bleed
first thing i will do quick neuro exam and if any new deficit i will send urgent ct brain
at the same time i start controlling bp but carefully not too fast, i can use iv labetalol or gtn or nicardipine, target to bring systolic around 140
give simple analgesia for headache and admit to icu for close monitoring, if seizures appear i treat them
i will also inform vascular team and anesthesia immediately
preoperative risk factors are uncontrolled hypertension, contralateral carotid occlusion, recent stroke or tia, diabetes, old age, impaired autoregulation
algorithm is simple: neuro exam → ct if deficit → iv antihypertensive → gradual bp control → pain control → icu monitoring → treat seizures → inform team
This patient suffers hyperperfusion syndrome or ICH
the management would be supportive medical therapy including analgesics, mannitol, bp control with b blocker ccb and thiazides
urgent CT scan and carotid duplex
risk factors include uncontrolled HTN patients, patients on blood thinners
A1:
According to symptoms and timing ICH or HPS with cerebral oedema are most likely in this case
Ptn should be investigated TCD CT or MRI
Management after ABCD and O2 supply includes supportive ttt with analgesics mannitol steroids anti epilepsy anti HTN b blochers CCB dieuretics along with discontinuation of bl thinners
A2:
Pre op RF
age smoking dyslipidemia renal disease anti coagulation anti platelets poor control of HTN
a case of mostly post CEA hyper-perfusion syndrome vs intracranial hemorrhage
Management Plan :1- immediate ABC assessment: airway,breathing & circulation (IV access)
2- check neurological status : GCS
3- Monitor blood pressure: BP,ECG,O2 saturation
Target SBP= 100-140 mmHg
Use short acting anti hypertension drugs as Labetalol (B blocker ) / Nicardipine
4- Neurological Evaluation: Urgent CT brain to exclude intracranial hemorrhage or stroke
5- Supportive Care : Elevate head of bed 30 degree, Analgesic, ICU admission
Risk Factors:1- Uncontrolled preoperative hypertension.
2- Longstanding hypertension
3-Older age (65 y).
4-Diabetes, renal impairment.
5-Recent high-grade symptomatic stenosis (TIA/stroke).
6-Intraoperative cerebral ischemia or clamp intolerance.
7- Severe ipsilateral carotid stenosis (>90%).
8-Contralateral carotid occlusion or severe disease.
Alogorithm :Patient post-CEA with High BP (190/100) + Headache
│
▼
Assess ABC + Neuro status + Monitor BP
│
▼
Exclude surgical cause (bleeding, airway, pain, anxiety)
│
▼
Severe Hypertension with Headache/Deficit?
│
┌────────┴─────────┐
▼ ▼
Neurological deficit No deficit
│ │
Urgent CT Brain Control BP
(rule out ICH/Stroke) with IV Labetalol/Nicardipine
│
▼
ICH → Neurosurgery consult
Ischemia → Stroke team
Normal CT → Hyperperfusion syndrome
│
▼
Strict BP control + ICU monitoring