Traumatic Vs Spontaneous�Subarachnoid Hemorrhage (SAH)

Traumatic Vs Spontaneous�Subarachnoid Hemorrhage (SAH)

1. Traumatic Vs Spontaneous Subarachnoid Hemorrhage (SAH) Dr Amit Agarwal Professor of Neurosurgery Narayana Medical College and Hospital Nellore (AP)

2. Conflict of interest: None Financial support: Nil Disclosures

3. Many more conditions Trauma first or pathology first Seizures Trauma Loss of consciousness Trauma Intracranial hemorrhage Trauma Focal weakness Trauma

4. It can be spontaneous It can be traumatic Spontaneous SAH can lead to trauma (aneurysmal rupture while driving) Rupture of traumatic aneurysms can lead to SAH Puzzle of spontaneous versus traumatic SAH

5. What is subarachnoid space? What is SAH? What are the causes of SAH? What are the clinical features? How to make a diagnosis? How to plan the management? First thing first "The eye cannot see what the mind does not know”

6. What is subarachnoid space?

7. Subarachnoid Hemorrhage (SAH) is a collection of blood into the subarachnoid space Common source is arteries (ruptured aneurysm or arteial tears) traversing through the subarachnoid space What is SAH?

8. Traumatic SAH (26-53% of all trauma cases) Spontaneous SAH Spontaneous rupture of an aneurysm (80-85%) Many other diseases Cerebral amyloid angiopathy Arteriovenous malformation Septic aneurysm Cocaine associated SAH Moya- moya disease Sickle cell disease Pituitary apoplexy Vertebral dissection Carotid dissection Causes of SAH

9. Clinical presentation   sSAH tSAH Headache Sudden severe headache Thunderclap headache Worst headache ever  varying severity Sentinel headache  ✓   ✕ Altered consciousness ✓ ✓ Confusion and irritability ✓ ✓ Nausea and vomiting ✓ ✓ Meningeal irritation ✓ Please do not elicit neck rigidity Seizures ✓ ✓ Neurological deficits ✓ ✓ Retinal hemorrhages ✓ ✓ Trauma    ✓

10. Elaborate clinical history A complete neurological evaluation Level of consciousness Pupillary examination Reflexes Motor response Clinical history Examination Look for signs of injuries including C-spine Imaging appearance A high index of suspicion Algorithm to approach

11. Investigations: Non-contrast CT scan Initial investigation of choice Presence of SAH Distribution of blood Extent of hemorrhage Any associated lesions

12. Case courtesy of Dr Henry Knipe, Radiopaedia.org , rID : 33934 Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org , rID : 4852

13. Angiography CTA DSA MRA Lumbar puncture (Please rule out any intracranial mass lesions) Further investigations

14. Management   sSAH tSAH Airway ✓ ✓ Breathing ✓ ✓ Circulation ✓ ✓ Disability assessment ✓ ✓ Anti-epileptics ✓ ✓ Supportive management ✓ ✓ Management of raised ICP ✓ ✓ Management of vasospasm ✓ ✓ Euvolemia ✓ ✓ Normothermia ✓ ✓ Treatment of underlying etiology Aneurysm clipping  

15. Even though etiological classification categorizes traumatic and non-traumatic or spontaneous (SAH) separately, in many aspects the clinical presentation and management significantly overlaps However, differentiation between tSAH and sSAH is important as the definitive treatment is not same Conclusions

16. Long B, Koyfman A, Runyon MS. Subarachnoid Hemorrhage : Updates in Diagnosis and Management. Vol. 35, Emergency Medicine Clinics of North America . Elsevier ; 2017. p. 803–24. Perry JJ, Alyahya B, Sivilotti MLA, Bullard MJ, Émond M, Sutherland J, et al. Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage : prospective cohort study . BMJ. 2015 Feb 18;350:h568. Serrone JC, Maekawa H, Tjahjadi M, Hernesniemi J. Aneurysmal subarachnoid hemorrhage : pathobiology , current treatment and future directions . Expert Rev Neurother . 2015 Apr 3;15(4):367–80. Edjlali M, Rodriguez-Régent C, Hodel J, Aboukais R, Trystram D, Pruvo J-P, et al. Subarachnoid hemorrhage in ten questions . Diagn Interv Imaging . 2015 Jul 1;96(7–8):657–66. Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage . Lancet (London, England ). 2017 Feb 11;389(10069):655–66. Modi N, Agrawal M, Sinha V. Post- traumatic subarachnoid hemorrhage : A review . Neurol India. 2016;64(7):8. Graff-Radford J, Fugate JE, Klaas J, Flemming KD, Brown RD, Rabinstein AA. Distinguishing clinical and radiological features of non- traumatic convexal subarachnoid hemorrhage . Eur J Neurol . 2016 May;23(5):839–46. Wong B, Ong BB, Milne N. The source of haemorrhage in traumatic basal subarachnoid haemorrhage . J Forensic Leg Med . 2015 Jan;29:18–23. Armin SS, Colohan ART, Zhang JH. Traumatic subarachnoid hemorrhage : our current understanding and its evolution over the past half century . Neurol Res. 2006 Jun 19;28(4):445–52. Lin TK, Tsai HC, Hsieh TC. The impact of traumatic subarachnoid hemorrhage on outcome : A study with grouping of traumatic subarachnoid hemorrhage and transcranial Doppler sonography . J Trauma Acute Care Surg . 2012;73(1):131–6. Al- Khindi T, Macdonald RL, Schweizer TA. Cognitive and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage . Stroke . 2010 Aug;41(8):157–74 . References

17. Thank You