CLINICAL AND NEUROIMAGING

STUDIES IN CASES OF SPONTANEOUS SUBARACHNOID HAEMORRHAGE

INTRODUCTION

Subarachnoid haemorrhage (SAH), mostly from

aneurysms account for about 4.5 – 13% of all strokes.

The incidence of SAH has remained stable over

the last 30 years.

The reported incidence of SAH in the US,

Finland & Japan is high, while it is low in New

Zealand and Middle East.

INTRODUCTION

Incidencen/100,000 patients 95% CI

Finland22.0

USA12.0

Japan23.0

New Zealand14.3

Australia26.4 ‡

Netherlands7.8

Iceland8.0

Greenland Eskimo9.3

Denmark3.1

Faeroe Islands7.4

Indians4.3

Qatar5.1

Overall10.5‡ Not adjusted for sex & age to the same reference population

INTRODUCTION

Aetiology:

Ruptured intracranial aneurysms. (Commonest)

Cerebral AVMs.

CNS vasculitis.

Cerebral artery dissection

Rupture small superficial artery

Rupture of an infundibulum

Coagulation disorders.

INTRODUCTION

Dural sinus thrombosis &/or AV fistula.

Spinal AVMs

Pretruncal non-aneurysmal SAH

Rarities: - Tumours

- Sickle cell disease

- Cocaine abuse

- Atrial myxoma

- Pituitary apoplexy

No cause in 7 – 10%

INTRODUCTION

Aetiology:

Risk factors:

Unruptured aneurysms Hypertension

Smoking Race

Age Gender

Alcohol consumption ADPCK

Connective tissue disorders

INTRODUCTION

Clinical presentation

Meningismus 64%

Coma 52%

Nausea & vomiting 45%

No localization sign 39%

Global headache 32%

Occipital headache 21%

INTRODUCTION

Clinical presentation

Motor deficit 17%

Dysphasia 13%

Confusion 12%

Intraocular haemorrhages 12%

Anisocoria 12%

INTRODUCTION

Reflex changes 19%

Clinical presentation

Lateralized headache 8%

Third nerve palsy 7%

Sensory disturbance 5%

INTRODUCTION

Papilloedema 11%

Homonymous hemianopsia 9%

Complications

Ischaemic deficits 27%

Hydrocephalus 12%

Brain swelling 12%

Recurrent haemorrhage 11%

Intracranial hematoma 8%

Pneumonia 8%

INTRODUCTION

Gastrointestinal haemorrhage 4%

SIADH 4%

Pulmonary oedema 1%

Seizures 5%

INTRODUCTION

Complications

Investigations

Computed Tomography (CT)

Hydrocephalus 20%

The presence of intraventricular blood (13-28%)

Intraparenchymal blood (20-40%)

Subdural blood (1 - 3%)

INTRODUCTION

INTRODUCTION

Investigations

Computed Tomography (CT)

The pattern of SAH

Blood in cistern and fissures

With presence of multiple aneurysms it detect which one bled

INTRODUCTION

Investigations

Lumbar puncture (LP):

Elevated opening pressure

Xanthochromia

Elevated proteins

RBCs > 100.000 cm 3

INTRODUCTION

Investigations

CT angiography (CTA):

Suspicion of an aneurysm on conventional CT

Follow up of previously diagnosed aneurysm not planned for surgeryFollow up of aneurysm anatomy after surgery

Detection of ruptured aneurysms

Screening

INTRODUCTION

Investigations

MRI:

A unique method for identifying aneurysm in patient who not reffered till after 5 – 10 days, and brain CT showed no subarachnoid blood.

FLAIR MRI is more sensitive than CT in detection of acute SAH.

INTRODUCTION

Investigations

MRA:

For detecting aneurysm with sensitivity 85% and specificity around 90%.

For vasospasm identification the sensitivity is 92% and specificity 97%.

INTRODUCTION

Investigations

TCD:

Highly specific 100%, but relatively insensitive in detecting vasospasm.

Assess the intraaneurysmal dynamics.

INTRODUCTION

Investigations

Cerebral angiography:

The gold standard for the diagnosis of the intracranial aneurysm.

Negative in 20%.

INTRODUCTION

Investigations

Cerebral angiography:

Complications:

- Hypersensitivity to contrast agent.

- TIA

- TGA

- Death 1/20 – 40.000

Management

General

- Nursing - Nutrition

- Blood pressure - Fluid and electrolytes

- Pain

- Prevention of DVT, or pulmonary embolism

INTRODUCTION

Vasospasm

Prophylactic treatment:

- CCB (Nimodipine) - Olprinone

- Tirilazed

- Other investigational drugs (FK 506, TBC 11.251, L-Argininive monoclonal antibodies. Defferoxamine and prostacyclines, AVS, CGU.

INTRODUCTION

Management

- Intrathecal sodium nitroprusside

- Nitroglycerine

- Cyclosporin - Steroids

INTRODUCTION

Vasospasm

Curative treatment:

Management

- Hyperdynamic Therapy (Triple H therapy)

- Barbiturate coma

- Cisternal irrigation

- Gene therapy

- Angioplasty

- Intra-arterial injection of vasodilator

- Intra-aortic counterpulsation

INTRODUCTION

Vasospasm

Curative treatment:

Management

Antifibrinolytic drugs (TEA, EACA)

Early surgical intervention

INTRODUCTION

Management

Rebleeding

Conservative

Repeated LP

Vetriculostomy

Shunt

INTRODUCTION

Management

Hydrocephalus

Hyponatraemia

Cardiac complications

Pulmonary complications

INTRODUCTION

Management

Systemic complication

Trapping

Proximal ligation (hunterian ligation)

Thrombosing aneurysm with GDC & Balloon embolization.

INTRODUCTION

Management

Endovascular & nonsurgical techniques to treat the aneurysm

Clipping

Wrapping

Coating

INTRODUCTION

Management

Surgical treatment

AIM OF THE WORK

This work is carried out to evaluate the

clinical presentation and various diagnostic

procedures of spontaneous subarachnoid

haemorrhage.

AIM OF THE WORK

PATIENTS & METHODS

PATIENTS & METHODS

PATIENTS & METHODS

PATIENTS WERE SUBJECTED TO

History taking

Laboratory investigations

Neurological examination

Lumbar puncture

CT scanning & CTA

MRI FLAIR

MRA

4 vessels angiography

PATIENTS & METHODS

Table : Hunt and Hess scale

GradeDescription

IAsymptomatic or mild headache and slight nuchal rigidity

IICr. N. palsy, moderate to severe headache, nuchal rigidity

IIIMild focal deficit, lethargy, or confusion

IVStupor, moderate to severe hemiparesis, early decerebrate rigidity

VDeep coma, decerebrate rigidity, moribund appearance

Modified classification adds the following:

0Unruptured aneurysm

IaNo acute meningeal/brain reaction, but with fixed neuro deficit

Add one grade for serious systemic disease (eg HTN, DM, COPD, or atherosclerosis) or severe vasospasm on arteriography

PATIENTS & METHODS

RESULTS

SAH

Number and percentage of stroke patients admitted to the neurology department in Mansoura Emergency University

Hospital in the period of the study

Haemorrhagic stroke Ischemic stroke

RESULTS

Male

Sex distribution

Female

RESULTS

60 - 69 >70

Age distribution in males

30 - 39 40 - 49 50 - 59

RESULTS

60 - 69 >70

Age distribution in females

30 - 39 50 - 5940 - 49

RESULTS

0

5

10

15

20

I II III IV V

Males Females

Sex distribution in the different grade of the studied patients

RESULTS

0

20

40

60

80

100

No

%

GI GII GIII GIV GV Total

Clinical Grading System according to H & H.

RESULTS

0

20

40

60

80

I II III IV V

Mean SD SE

Mean age in the different grade of the studied patients

RESULTS

6 PM : 12 AM

percentage of patients according to time of onset of SAH

12 AM : 6 AM 6 AM : 12 PM

12 PM : 6 PM

RESULTS

0

1

2

3

4

5

6

7

8 No. of patients

Incidence of SAH in the 24 hours SAH

RESULTS

0

10

20

30

40

Hypertension

Dyslipidemia

Diabetesm

ellitus

Smoking

Hyperuricemia

Drug abuse

Family history

Collagenvasculardisease

Bleedingdiasthesis

Frequency of risk factors

RESULTS

No. ofdeath

%

First week

Second week

Third week

Fourth week

Total

30 days case fatality rate

RESULTS

DEATH (NO)

DEATH (YES)

TOTAL

I

%w

thin

GR

AD

E

II

%w

thin

GR

AD

E

III

%w

thin

GR

AD

E

IV

%w

thin

GR

AD

E

V

%

wth

in G

RA

DE

To

tal

%w

thin

GR

AD

E

The relation between the clinical grades and mortality rate

RESULTS

0

10

20

30

40

%Rebleeding Vasospasm Initial haemorrhage Others

Causes of short term mortality

RESULTS

0

20

40

60

80

100

%

ASAH PMH Negative

CT finding in our series

RESULTS

0

10

20

30

40

50

60

70

80

%

MCA aneurysm A com A aneurysm Multiple aneurysms

Vasospasm No aneurysm AVM

MRA finding of the examined patients

RESULTS

0

10

20

30

40

50

60

%

MCA aneurysm PCA aneurysm

A Com A aneurysm ICA aneurysm

MCA & A Com A aneurysm Negative

Conventional angiography finding in our series

RESULTS

CASE 1

RESULTS

RESULTS

RESULTS

RESULTS

CASE 2

RESULTS

RESULTS

RESULTS

RESULTS

RESULTS

CASE 3

RESULTS

RESULTS

RESULTS

RESULTS

RESULTS

CASE 4

RESULTS

RESULTS

RESULTS

RESULTS

RESULTS

CONCLUSIONS

Sudden , explosive headache is a cardinal but

nonspecific feature in the diagnosis of SAH : in

general practice , the cause is innocuous in nine out

of the ten patients in whom this is the only symptom

The incidence of subarachnoid haemorrhage is

3.8% of all strokes in our locality ,and presenting

12.4% of the haemorrhagic strokes.

CONCLUSIONS

48% of patients presented by sudden , severe

headache , nuchal rigidity and cranial nerve

palsy , while 24% presented by stuporous

consciosness and severe hemiplegia , and only 6

% with deep coma .

Most patients are below sixty years of age , and

women are more suffered . Risk factors are the

same as for stroke in general ; genetic factors

operate in only a minority .

CONCLUSIONS

30 day case-fatility is 46% , the majority of them in

the first week after admission due to rebleeding

and the effect of this initial haemorrhage .

Hypertension , smoking , diabetes, age and

dyslipedemia are the main risk factors .

CONCLUSIONS

MRI FLAIR is superior than CT in detecting SAH in

subacute phase where the patient come after the

onset by one or two weeks .

Four-Vessels angiography more sensitive in

detecting intracranial aneurysms in comparison to

MRA.

CT scanning is mandatory in all , to be followed by

(delayed ) lumber puncture if CT is negative .

CONCLUSIONS

RECOMMENDATIONS

The Clinician should have a high index of

suspicion that a sudden , severe , unexplained

headache in any patients could represent an

acute subarachnoid haemorrhage .

If the CT scan is positive , lumber puncture is

unnecessary and dangerous due to risks of

aneurysm rebleeding or transetentorial brain

herniation .

RECOMMENDATIONS

Once the diagnosis is confirmed with a CT scan , a

neurosurgeon who can ultimately treat the patient

should be contacted immediately . Delay in

transfer may prove fatal because of potential for

aneurysm rebleeding prior to intervention

RECOMMENDATIONS

If the CT scan is negative , lumber puncture may

be helpful if the history of ictal headache is not

typical of subarachnoid haemorrhage

RECOMMENDATIONS

Blood pressure must closely monitored and

controlled following SAH . Hypertension will

increase the chance of catastrophic rebleeding .

Blood pressure control should be initiated

immediately upon diagnosis of SAH.

RECOMMENDATIONS

Preoperative medications include prophylactic

anticonvulsants, and antihypertensives as needed .

Not initiate antifibrinolytic therapy unless surgery is

not considered within 48 hours of initial SAH.

RECOMMENDATIONS

All X-rays , MRI scans , and lab work sent with the

patients to avoid needless repetition .

Surgery or endovascular coiling to obliterate the

ruptured aneurysm should performed as soon as

possible after the onset of SAH. Poor grade

patients , grades 4 and 5 , are treated non-

operatively or neurointerventionally until their

clinical condition improves .

THANK YOU