Neurosurgeons talk about a Hunt and Hess Scale. It's not a scale that we use as nurses
but it helps you identify if you're coming in to take care and have an idea of, "What is their Hunt and Hess?" If the doctor says they're a Hunt and Hess of three then you would have an idea that this person is going to be a little bit drowsy,
that they maybe have a severe headache, a little bit of local rigidity. A Hunt and Hess of four or five is designated to a very poor outcome. If they come in at a four to five they may have between a 70 and 80% chance mortality rate.
The thing I found was interesting with the H Susie came in and she was alert and oriented she had photophobia, they gave her a Glasgow coma score of 12.
She obeyed commands, she knew herself. She just liked a really dark room. We kept the shades down. Usually a real classic sign, you come into their room to pick them up and they've got a washcloth across their forehead,
don't they? The room's real quiet. We do want to keep these people on subarachnoid hemorrhage precautions before their aneurysm is clipped or coiled. We like to keep the room quiet.
We like to keep the blinds down. Keep the family a little bit quiet. We have an open visitation. I don't know if y'all have that in your facility but it can get to be a little bit like a three-ring circus
if everybody in the world comes and in East Texas if mama's in the hospital the kids, the grandkids, the aunts, the uncles, the adopted cousins, they all come and it's really a matter of crowd control
and in these days where people are all worried about their scores of being a friendly hospital there are many times when we have to be the big, "You know you need to get quiet "you need to get out of the room." If there's everybody around the bed she can't rest.
And if she had an urgent need I couldn't get to her so y'all need to get over on that side of the room and thankfully at my facility our rooms are rather large so we can kind of keep people a little bit further back.
If a person has a lot of co so I come in as a Hunt and Hess three but maybe I've got COPD or real bad hypertension then it would increase my Hunt and Hess score
by another grade if I had other co-morbid problems.
Next are our AV malformations, arteriovenous. With AVMs, arteries connect directly to the veins causing the blood to flow very fast through these vessels. These and because of the fast flow this makes them a potentially more aggressive vascular malformation.
The absence of capillaries, which is a network of small blood vessels that normally connect arteries to veins and deliver oxygen to cells, this creates a shortcut for blood to pass directly from arteries to veins by passing in the tissue. This can lead to tissue damage and
the death of nerve and other cells, resulting in arteriovenous shunting. When these occur in the brain they are treated in our Neuro-Interventional Radiology Suite and they're obviously of special concern because of the risk of bleeding of the AVM
and resulting potential neurological damage. Most often AVMs are congenital but they can appear sporadically. In some cases the AVM may be inherited but it's more likely typically that other inherited conditions increase the risk of a patient
developing an AVM, as we see in the case of HHT. These may look like a pseudo-capillary malformation with pulsation at palpation or you can appreciate a bruit. It may look like an enlarging red, warm, painful lesion, it could be ulcerated and bleeding. Obviously these can cause a patient significant pain.
Management of AVMs is particularly challenging due to their unpredictable course and high morbidity rate because, again, of that high flow shunting nature of AVMs.
The importance of the meta-analysis and I like to talk about this for a little bit, we call this, it's kinda like the key study that really promoted the use of meta-analysis back in 1990's
so the Streptokinase study. I know this is a busy slide. So this is a forest plot that's in a meta-analysis. You don't need to know that, what you need to look at is the P-value. So the P-values, if you notice, these are 33 studies.
If you look at the P-values, I'm sorry this is 36 studies. If you look at the P-values, 33 of those studies were non significant. So if you were to just look at those studies individually, well 33 studies were non significant and only six studies were significant.
What does that mean? So in your mind you would think Streptokinase doesn't work for thrombolysis right? Well that's what people thought for years. On the Streptokinase study, they pooled data from 33 studies over a 30 year span.
The first Streptokinase study came out in 1959 and they continually studied it until 1988. The overall conclusions from the medical community engaged in cardiac health care said that Streptokinase didn't work because there was so many studies that proved that it didn't work.
However, like I said, I misread the numbers. So 27 studies reported no significance. Six studies reported significance. Out of six out of 33, what are you gonna believe? But when they put these studies together
and performed the actual meta-analysis, it was Dr. Lao, they pulled a sample size of 36,974 patients. So they basically took all the sample sizes from all of those 33 studies and pooled them together. What they found when they pooled the numbers of patients it provided a better effect size.
So meta-analysis showed a risk reduction of 21%. The P-value was less than .000008, which is highly significant. So when they combined all the studies they actually found out that Streptokinase decreased your risk of developing a thrombotic even and dying from it
than if you did not get it. So that kind of... And this was published in 1992 and look at the date when it first started. So they should have been using Streptokinase for years but because of the lack of the meta-analysis,
they had no idea. The meta-analysis just kind of hammered that home how important meta-analysis and identifying, 'cause you may have studies that with small sample sizes that don't come out significant. However, if you start pooling a bunch
of randomized controlled trials you're going to see a definite significance if it's there.