Subarachnoid

HEMORRHAGE

DR RAJESH T EAPEN

ATLAS HOSPITAL

MUSCAT

Definition

• Subarachnoid haemorrhage is

defined as bleeding into the

subarachnoid space within the

intracranial vault.

Review of anatomy

Incidence

• The incidence of subarachnoid haemorrhage is 9.1 per

100,000 annually.

• Risk increases in older age 60% higher in age above 80

• Risk of SAH is relatively higher in women over 55 years

than men

Risk factors

• Race

• Sex

• Age

• Genetics

• Smoking

• Alcohol

Etiology

• Head trauma

• Intra cranial aneurysm

Increased blood

pressure

Increased blood flow

Blood vessel disorders

Genetics

Infections

Types of aneurysm

• Berry (saccular)aneurysm

• Giant (fusiform) aneurysm

• Mycotic aneurysm

• Charcot –Bouchard aneurysm

• Traumatic aneurysm

Location

Pathophysiology

Mass effect Rupture effect

Rupture of cerebral aneurysm

Bleeding into subarachnoid space

Stroke syndrome develops

Increased ICP

Risk Factors • Behavioral

• Hypertension

• Smoking

• Alcohol Abuse

• Drug Abuse

• Stress

• Low BMI

• Non-Behavioral

• Female Sex

• History of previous SAH

• Family history

• Polycystic Disease

• Age

How are SAH graded?

GCS 15, only CN deficit if any

Grade 1 No blood

GCS 13-14, no deficit

Grade 2 Diffuse blood, no clots & <1mm

GCS 13-14, with deficit

Grade 3 Clots & blood 1mm or more

GCS 7-12, +/- deficit

Grade 4 ICH or intra-ventricular clots

GCS 3-6 +/- deficit Grade 5

Fischer grading

Clinical Presentation • “The worst headache of my life”

• Sudden, severe onset with or without LOC (loss of

consciousness)

• Generally associated with nausea and vomiting, stiff neck,

photophobia, restlessness and agitation

• Seizures may occur (most commonly in first 24 hours)

• Typically asymptomatic until rupture occurs

Some times low back pain and bilateral radicular leg pain.

Signs

• Neck stiffness

• Impaired level of consciousness in some patients

• Subhyaloid haemmorhage on optic funduscopy

Kernigs sign

Brudzinskis sign

Grading of SAH

Hunt-Hass classification

Category Criteria

Grade 1 Asymptomatic or mild headache

Grade 2 Moderate-to-severe headache, nuchal rigidity, and

no neurological deficit other than possible cranial

nerve palsy

Grade 3 Mild alteration in mental status (confusion, lethargy),

mild focal neurological deficit

Grade 4 Stupor and/or hemi paresis

Grade 5 Comatose and/or decerebrate rigidity

GRADING/ CLASSIFICATION OF SAH:

Diagnosis • GOLD STANDARD: Non-Contrast

head CT

• Almost 100% sensitive within first

3 days

• Aneurysms <3mm may not show

• Lumbar Puncture – to show

xanthochromia

• MRI of the head

• Cerebral angiography

CT Scan non-

contrast showing

blood in basal

cisterns (SAH) –

so called “Star-

Sign”

Management

Medical management

• Acute care

• If patient is comatose ventilator assistance

• ABG analysis

• Emergency CT scan

• Cardiac monitoring

• Pain management

• The goal of treatment is to prevent re bleeding and

cerebral vasospasm

• Re bleeding

• Bed rest

• Recombinant activator factor VII

• Calcium channel blocker

• Smooth muscle relaxants

• Triple H therapy

Hypervolumia

Hypertension

Hemodilution

• Steroids

• Antihypertensive

• Antipyretics

• Anticonvulsants

• Analgesics

• Sedatives

• Stool softeners

Differential Diagnosis

• Migraine

• Drug Abuse

• Arterial dissection

• Vasculitis

• Anticoagulant Use

Pharmacological Treatment

• Monitor CVP (Central Venous Pressure) – if <7 0.9% NS bolus

• Maintain SBP 90-140mmHg until aneurysm is secured (clipping or

coiling)

• If non-traumatic – control vasospasms with Nimodipine 60mg q4h

X 21 days or 30mg q2h X21 days

• Prevent seizures – levetiracetam 500mg IV Q12h

• Control blood glucose levels

Nimodipine (Nimotop®)

• Indication: Subarachanoid Hemorrhage (Hunt & Hess 1-V)

• MOA: Calcium channel blocker – prevents calcium entry into

smooth muscle cells during depolarization which inhibits

vasoconstriction

• Dose: 30mg PO q2h for 21 days OR 60mg PO q4h for 21 days

• Interactions: CYP3A4 Inhibitors and Inducers

• Pharmacokinetics: 95% protein bound, hepatic metabolism

• Monitoring: BP, HR, Neurological improvement

Surgical management

clipping of aneurysm

22/02/2015© 2009, American Heart Association. All rights reserved.

Clipping

Left image arrow -Angio with Large aneurysm

Right image arrow – Angio showing aneurysm post clipping

Coiling of aneurysm

22/02/2015© 2009, American Heart Association. All rights reserved.

Coiling

Coil system embolization: immediate

result

Angio showing large ICA aneurysm

Same aneurysm - Post GDC Coiling

Infectious problems in SAH patients

• important to distinguish saccular aneurysms from mycotic (frequently post-bacteremic) aneurysms

• postoperative infections

• postoperative meningitis may be aseptic, but this is a diagnosis of exclusion

• particularly a problem in the SAH patient because the hemorrhage itself causes meningeal reaction

• complications of critical illness

• complications of steroid use

Seizures in SAH patients

• about 6% of patients suffer a seizure at the time of the

hemorrhage

• distinction between a convulsion and decerebrate posturing

may be difficult

• postoperative seizures occur in about 1.5% of patients despite

anticonvulsant prophylaxis

• remember to consider other causes of seizures (e.g., alcohol

withdrawal)

Seizures in SAH

patients

• patients developing delayed ischemia may seize

following reperfusion by angioplasty

• late seizures occur in about 3% of patients

Seizure management in

SAH

• seizures in patients with unsecured aneurysms may

result in rebleeding, so prophylaxis (typically

phenytoin) is commonly given

• even a single seizure usually prompts a CT scan to

look for a change in the intracranial pathology

• additional phenytoin is frequently given to raise the serum

concentration to 20+ ug/mL

• lorazepam to abort serial seizures or status epilepticus

Nursing management

• Altered neurological function related haemorrhage from

cerebral aneurysm

• Pain due to cerebral haemorrhage

• Sensory input distortion related to meningeal irritation

• Potential for seizure related to cerebral irritation

• Potential for neurological deterioration related to re

bleeding or cerebral vasospasm

Complication

• Rebleeding

• Hydrocephalus

• Intraventricular haemorrhage

• Increased intracranial pressure

• Intracerebral haemorrhage

• Seizures

• Cerebral vasospasm

COMPLICATIONS

• Respiratory complication

• Venous complication

• Cardiovascular complication

• Fluid and electrolyte disturbance

• Gastrointestinal complication

Complications with SAH • Vasospasm

• Blood vessel goes into spasm causing ischaemia - stroke

• To prevent keep them filled with at least 3L fluid day & nimodipine IV/PO & insert central line to monitor central venous pressure – aiming for 8-10

• Suspected with deteriorating GCS/new neurological deficit

• Treatment – Urgent CT brain to rule out a bleed as a cause of the deterioration then urgent angiogram to diagnose & treat vasospasm

• Greatest risk of vasospasm is days 4-7 but significant risk for first 3 weeks after bleed, therefore must use preventive measures for at least 3 weeks

Complications with SAH • Hyponatraemia

• Susceptible due to being fluid loaded & cerebral salt wasting

• Cerebral salt wasting = renal loss of sodium due to intracranial pathology ? Cause. Loss of water & salt (whereas SIADH is loss of salt & retention of water)

• Treat with normal or hypertonic saline

• If refractory may need a mineralocorticoid e.g. fludrocortisone to stimulate renal reabsorption – but this should only be used under instructions from consultant endocrinologist

Complications with SAH • Seizures

• A seizure is a disturbance of sensation, movement or consciousness

• All seizures originate from the surface of the brain – cortex

• Blood is an irritant to the cortex

• Prophylaxis with phenytoin or levetiracetam

• Ensure phenytoin levels are therapeutic

• Treat as seizure from any cause & suspect re-bleed

Complications with

SAH

• Venous Thrombo Embolism

• On bed rest

• TEDS (Thrombo Embolism Deterrent Stockings)

• Prophylactic enoxaparin as soon as consultant sees fit

• Always keep VTE in the back of your mind

Prognosis

Hunt and Hess: