Background

Etiology of SAH

Risk factors of SAH

Diagnostic investigations

Management of SAH in ED

Disposition

Complication of SAH

A 60 year old male k/c/o HTN presented to the emergency department complaining of a sudden, acute onset headache “worst headache of my life “ that radiated into his neck. Symptoms began three hours

prior to presentation and were associated with nausea and vomiting.

Subarachnoid hemorrhage (SAH) is a pathologic condition that exists when blood enters the subarachnoid space

SAH

traumatic Non traumatic

Aneurismal

85%

Non aneurismal

15%

perimesencephalichemorrhage

50%

Other disorders

CATEGORY CAUSES

TRAUMA CLOSED, PENETRATING, ELECTRIC,ETC…

VASCULAR ANEURYSMS, ATHEROSCLEROSIS, AVM, VASCULITIDES

IDIOPATHIC BENIGN PERIMESENCEPHAIC SUBARACHNOID

HEMORRHAGE

BLOOD DYSCRASIAS LEUKEMIAS, HEMOPHILIAS, THROMBOCYTOPENIAS

INFECTIONS DENGUE, LEPTOSPIROSIS, BACTERIAL MENINGITIS

TOXINS AMPHETAMINES, COCAINE, NICOTINE,

ANTICOAGULANTS

NEOPLASMS GLIOMAS, MENINGIOMAS, HEMANGIOBLASTOMA, ETC

Incidence about 9-10/100,000/yr

Higher in Japan (3 times) and Finland

Mean age of onset 51 years (6th decade)

Facts and figuresMen predominate until age 40, then more women (55%); some studies – 3:2 ratio

30 % rupture during sleep??

About 50 % of patients with an aneurysm have warning prior to SAH (6-20 days).

Average case fatality rate for SAH was 51 %

Population-based study in England with essentially

complete case ascertainment

24 hour mortality: 25%

7 days: 37%

30 days: 45%

Pobereskin JNNP 2001;70:340-3

Hypertension

Cigarette smoking

Oral contraceptives

Alcohol consumption

Diurnal variations in blood pressure

Pregnancy and parturition

Slight increased risk with advancing age

Following cocaine abuse

Headache:Features: Sudden and severe "worst headache of my life“

Associated Symptoms: brief loss of consciousness (coma is unusual) 57%

nausea or vomiting 77%

meningismus 35%??

Seizure <10% poor prognostic indicator

CT Scan :

Within 6-12 hr sensitivity 100% (Perry JJ ,et al, 2011)

CT sensitivity progressively declines over time to about 58% at day five.

Lumbar Puncture:

LP is mandatory if strong suspicion of SAH despite negative CT

Negative CT and LP effectively eliminate the diagnosis of SAH

Follow-up LP unnecessary , If CT scan preformed within 6 hr.

Findings: elevated opening pressure and an elevated RBC count in all

tubes, Xanthochromia

MRI:

Less sensitive than CT scan in diagnosing acute SAH

FLAIR and T2 have a high sensitivity in patients with a

sub-acute presentation of SAH

If there is a large amount of SAH particularly in the basal cisterns, sulci & fissures the physician should consider a ruptured aneurysm

Traumatic SAH occurs most commonly over the cerebral convexities or adjacent to otherwise injured brain (i.e. adjacent to a cerebral contusion)

Angiography:To determine the etiology of hemorrhage

DSA

MRA /CTA

CTA/MRAConventional angiography

•noninvasive tests•screening and pre-surgical planning•identify aneurysms 3 to 5 mm or larger

•Less resolution than conventional Angiography •Less sensitive

-Better resolution-High sensitivity in detecting aneurysm

-invasive

GRADE SIGNS/SYMPTOMS SURVIVAL

1 Asymptomatic/Minimal headache or neck stiffness

70%

2 Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy

60%

3 Drowsy/ minimal neurological deficit 50%

4 Stuporous with hemeparesis 20%

5 Comatose with decereberateposturing/response

10%

HUNT AND HESS IN 1968

GRADE GCS NEURODEFICIT

1 15 ABSENT

2 13-14 ABSENT

3 13-14 PRESENT

4 7-12 ABSENT/PRESENT

5 <7 ABSENT/PRESENT

WORLD FEDERATION OF NEUROSURGEONS (WFNS)

GRADE CT APPEARANCE

1 No blood detected

2 Diffuse deposition or thin layer with all vertical layers (in interhemispheric fissure, insular cistern, ambient cistern) less than 1 mm thick

3 Localized clot and/or vertical layers 1 mm or more in thickness

4 Intracerebral or intraventricular clot with diffuse or no subarachnoid blood

FISHERS

GRADE CT APPEARANCE

0 No SAH or IVH

1 Minimal SAH and no IVH

2 Minimal SAH with bilateral IVH

3 Thick SAH (completely filling one or more cistern or fissure) without bilateral IVH

4 Thick SAH (completely filling one or more cistern or fissure) with bilateral IVH

CLAASSENS MODIFICATION

ABC

Triage and transport patients with ALC or an abnormal neurologic examination to the closest medical center with a CT scan and neurosurgical backup.

ABCIntubation.Acute medical care:

Control BP (decrease risk of Rebleeding): sBP<160 or mean arterial BP <110Use Labetalol, nicardipine

DVT prophylaxis :pneumatic compression stockings.unfractionated heparin 5000 units TID can be added.

IV fluid analgesia kept at bed rest

Nimodipine {CCB} (60mg PO or NGT every 6hr) reduce incidence and severity of Vasospasm.

Antifibrinolytic agents (eg, tranexamic acid)Reduce risk of re-bleeding

Antiepileptic drug therapy and steroids: controversial

Statins: unknown mechanism but advisable

ICU bed

Neurosurgeon & neuroradiologist consultation: for surgical clipping or endovascular coiling

Nonaneurysmal SAH generally has a more benign course, so angiographic intervention is not typically undertaken in these cases.

Re-bleeding:8 to 23 %highest in the first 24 hoursManifestation : acute deterioration of neurologic status accompanied by appearance of new hemorrhage on CT scanAneurismal Rx is best way to prevent re-bleeding.

Vasospasm and Delayed cerebral Ischemia:40 to 60 %Late presentation: >3 daysManifestation: neurologic deterioration in LOCor new focal neurologic deficits

Hydrocephalus:15% of pt with SAH75% of pt resolve spontaneously

SeizureHyponatremia

Cardiac abnormalities:ECG changes:

ST segment depression, QT interval prolongation, deep symmetric T wave inversions, and prominent U waves

Left ventricular dysfunctionElevated trop I levelElevated BNP

http://ezproxy.squ.edu.om:2983/contents/clinical-manifestations-and-diagnosis-of-aneurysmal-subarachnoid-hemorrhage?source=search_result&search=subarachnoid+hemorrhage&selectedTitle=1~150

http://ezproxy.squ.edu.om:2983/contents/treatment-of-aneurysmal-subarachnoid-hemorrhage?source=see_link&anchor=H259178626

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http://emedicine.medscape.com/article/794076-overview#aw2aab6b4

http://www.medscape.com/viewarticle/803838_3