SUBARACHNOID HEMORRHAGE

Medical, Surgical, SAH, Subarachnoid Haemorrhage, Prognosis

1. Subarachnoid
HEMORRHAGE

DR RAJESH T EAPEN
ATLAS HOSPITAL
MUSCAT

2. Definition
•Subarachnoid haemorrhage is
defined as bleeding into the
subarachnoid space within the
intracranial vault.

3. Review of anatomy

4. 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

5. Risk factors
•Race
•Sex
•Age
•Genetics
•Smoking
•Alcohol

6. Etiology
•Head trauma
•Intra cranial aneurysm
Increased blood
pressure
Increased blood flow
Blood vessel disorders
Genetics
Infections

7. Types of aneurysm
•Berry (saccular)aneurysm
•Giant (fusiform) aneurysm
•Mycotic aneurysm
•Charcot –Bouchard aneurysm
•Traumatic aneurysm

9. Location

10. Pathophysiology
Mass effect Rupture effect

Rupture of cerebral aneurysm

Bleeding into subarachnoid space

Stroke syndrome develops

Increased ICP

11. 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

12. 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

13. 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.

14. Signs
•Neck stiffness
•Impaired level of consciousness in some patients
•Subhyaloid haemmorhage on optic funduscopy

15. Kernigs sign

16. Brudzinskis sign

17. 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:

19. 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

20. CT Scan non-
contrast showing
blood in basal
cisterns (SAH) –
so called “Star-
Sign”

22. Management
Medical management
•Acute care
•If patient is comatose ventilator assistance
•ABG analysis
•Emergency CT scan
•Cardiac monitoring
•Pain management

23. •The goal of treatment is to prevent re bleeding and
cerebral vasospasm
•Re bleeding
•Bed rest
•Recombinant activator factor VII

24. •Calcium channel blocker
•Smooth muscle relaxants
•Triple H therapy
Hypervolumia
Hypertension
Hemodilution

25. •Steroids
•Antihypertensive
•Antipyretics
•Anticonvulsants
•Analgesics
•Sedatives
•Stool softeners

26. Differential Diagnosis
•Migraine
•Drug Abuse
•Arterial dissection
•Vasculitis
•Anticoagulant Use

27. 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

28. 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

29. Surgical management
clipping of aneurysm

30. 22/02/2015© 2009, American Heart Association. All rights reserved.

Clipping

31. Left image arrow -Angio with Large aneurysm
Right image arrow – Angio showing aneurysm post clipping

32. Coiling of aneurysm

33. 22/02/2015© 2009, American Heart Association. All rights reserved.

Coiling

34. Coil system embolization: immediate
result
Angio showing large ICA aneurysm
Same aneurysm - Post GDC Coiling

35. 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

36. 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)

37. Seizures in SAH
patients
•patients developing delayed ischemia may seize
following reperfusion by angioplasty
•late seizures occur in about 3% of patients

38. 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

39. 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

40. Complication

•Rebleeding
•Hydrocephalus
•Intraventricular haemorrhage
•Increased intracranial pressure
•Intracerebral haemorrhage
•Seizures
•Cerebral vasospasm

41. COMPLICATIONS
•Respiratory complication
•Venous complication
•Cardiovascular complication
•Fluid and electrolyte disturbance
•Gastrointestinal complication

42. 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

43. 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

44. 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

45. 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

46. Prognosis
Hunt and Hess: