Subarachnoid HemorrhageSubarachnoid Hemorrhage

subarachnoid space

ventricles

Incidence of Aneurysmal Incidence of Aneurysmal SAHSAHStudies suggest that the incidence in the Studies suggest that the incidence in the

USA and Europe is 10 to 11 cases per USA and Europe is 10 to 11 cases per 100,000 population per year100,000 population per year

Overall, less than 2% of the entire Overall, less than 2% of the entire population will have an aneurysm; an population will have an aneurysm; an intracranial aneurysm will rupture in less intracranial aneurysm will rupture in less than 1% of the population and will be the than 1% of the population and will be the cause of death in 0.5%cause of death in 0.5%

Age and the Incidence of Age and the Incidence of Aneurysmal SAHAneurysmal SAH

Aneurysmal rupture is extremely rare in Aneurysmal rupture is extremely rare in the first decade of lifethe first decade of life

Incidence gradually increases each Incidence gradually increases each decade and peaks in the sixth decadedecade and peaks in the sixth decade

Gender and the Incidence of Gender and the Incidence of Aneurysmal SAHAneurysmal SAHThere is a clear female preponderance There is a clear female preponderance

overall; the ratio of females to males is overall; the ratio of females to males is 1.6: 11.6: 1

Before age 40 males and females were Before age 40 males and females were equally affected; after age 40 there is an equally affected; after age 40 there is an increasingly strong predominance of increasingly strong predominance of femalesfemales

Natural HistoryNatural HistoryPrognosis for Surgically Untreated SaccularPrognosis for Surgically Untreated SaccularIntracranial AneurysmsIntracranial Aneurysms

OVERVIEWOVERVIEWHighest mortality occurs immediately after the Highest mortality occurs immediately after the

hemorrhage and then decreases rapidlyhemorrhage and then decreases rapidlyRebleeding is estimated to occur in 50% of Rebleeding is estimated to occur in 50% of

ruptured aneurysms within 6 months of the ruptured aneurysms within 6 months of the first hemorrhage, and afterwards at 3% per first hemorrhage, and afterwards at 3% per yearyear

50-60% of patients die after rebleeding and 50-60% of patients die after rebleeding and 25% are left disabled25% are left disabled

Mortality at 1 day was 32%Mortality at 1 day was 32%Mortality at 1 week was 43%Mortality at 1 week was 43%Mortality at 1 month was 56%Mortality at 1 month was 56%

Mortality at 6 months was 60%Mortality at 6 months was 60%

Clinical presentationsClinical presentations

A lot of symptoms with minimal signs:A lot of symptoms with minimal signs:

1-severe thunder clump headache1-severe thunder clump headache2-repeated projectile vomiting2-repeated projectile vomiting3-photophobia3-photophobia4-meningeal signs4-meningeal signs

5-papilodema +/- subhyloid Hm5-papilodema +/- subhyloid Hm

Clinical Grading Scales for SAHClinical Grading Scales for SAH

Grade DescriptionGrade DescriptionHunt and Hess ScaleHunt and Hess Scale

1 Asymptomatic or minimal headache and slight nuchal 1 Asymptomatic or minimal headache and slight nuchal rigidityrigidity

2 Moderate to severe headache, nuchal rigidity, no 2 Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsyneurological deficit other than cranial nerve palsy

3 Drowsiness, confusion, or mild focal deficit3 Drowsiness, confusion, or mild focal deficit4 Stupor, moderate to severe hemiparesis, possible 4 Stupor, moderate to severe hemiparesis, possible

early decerebrate rigidity and vegetative disturbancesearly decerebrate rigidity and vegetative disturbances5 Deep coma, decerebrate rigidity, moribund 5 Deep coma, decerebrate rigidity, moribund

appearanceappearance

Clinical Grading Scales for Clinical Grading Scales for SAH SAH .../cont’d.../cont’d

Grade DescriptionGrade Description

World Federation of Neurological Surgeons ScaleWorld Federation of Neurological Surgeons Scale

1 Glasgow coma scale 15, no motor deficit1 Glasgow coma scale 15, no motor deficit2 GCS 13 to 14, no motor deficit2 GCS 13 to 14, no motor deficit3 GCS 13 to 14, with motor deficit3 GCS 13 to 14, with motor deficit4 GCS 7 to 12, with or without motor deficit4 GCS 7 to 12, with or without motor deficit

5 GCS 3 to 6, with or without motor deficit5 GCS 3 to 6, with or without motor deficit

Diagnosis of Subarachnoid Diagnosis of Subarachnoid

HemorrhageHemorrhage ((

Headaches accounts for 1-2% of visits to Headaches accounts for 1-2% of visits to ER; 1% of theses have SAHER; 1% of theses have SAH

About 80% of patients with nontraumatic About 80% of patients with nontraumatic SAH have a ruptured saccular SAH have a ruptured saccular aneurysm; of the other 20%, about 1/2 aneurysm; of the other 20%, about 1/2 have nonaneurysmal perimesencephalic have nonaneurysmal perimesencephalic hemorrhageshemorrhages

••The first diagnostic test should be non-The first diagnostic test should be non-contrast CT scanningcontrast CT scanning

••Timing of the CT scan in relation to SAH Timing of the CT scan in relation to SAH ictus is important; positive results ictus is important; positive results decrease with time; 98-100% are decrease with time; 98-100% are positive up to 12 hours after the ictus positive up to 12 hours after the ictus and 93% are positive in the first 24 and 93% are positive in the first 24 hourshours

Diagnosis of Subarachnoid Hemorrhage .../cont’d

LP should be performed in patients whose LP should be performed in patients whose clinical presentation suggests SAH and whose clinical presentation suggests SAH and whose CT is negativeCT is negative

‘‘Traumatic Tap’ occurs in up to 20% of LPs; Traumatic Tap’ occurs in up to 20% of LPs; Released hemoglobin is metabolized to the Released hemoglobin is metabolized to the pigmented molecular oxyhemoglobin (reddish pigmented molecular oxyhemoglobin (reddish pink) and bilirubin (yellow), resulting in pink) and bilirubin (yellow), resulting in xanthochromia. Oxyhemoglobin can be xanthochromia. Oxyhemoglobin can be detected within hours, but the formation of detected within hours, but the formation of bilirubin requires up to 12 hours to occur. bilirubin requires up to 12 hours to occur.

Diagnosis of Subarachnoid Hemorrhage .../cont’d

cathetercatheterarteriographyarteriography

anterioranteriorcirculationcirculation

posteriorposteriorcirculationcirculation

CT scan of a subarachnoid hemorrhage (SAH)

Treatment:Treatment:the aim of the treatment isthe aim of the treatment isto prevent a new rupture of the aneurysmto prevent a new rupture of the aneurysm

options:options:Medical non aneurysmal or surgery is contraindication Medical non aneurysmal or surgery is contraindication

surgical surgical clip or endovascular coilsclip or endovascular coils

Medical treatmentMedical treatment

1-Complete rest, sedation, keep the patient 1-Complete rest, sedation, keep the patient in dark room in dark room

2-Analgesic2-Analgesic3-IV fluid (2/3 of the requirement)3-IV fluid (2/3 of the requirement)

4-Nimodipine 60mg every 4hours4-Nimodipine 60mg every 4hours5-Laxative5-Laxative6-Control the BP6-Control the BP

clipclipopen surgeryopen surgery

where is the aneurysm?where is the aneurysm?

SAHSAH

where is the aneurysm?where is the aneurysm?

surgical clipsurgical clip

beforebefore afterafter

coilscoilsendovascular treatmentendovascular treatment

SAHSAH

rupture of an aneurysm rupture of an aneurysm at the tip of the basilar at the tip of the basilar arteryartery

beforebefore afterafter