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Subarachnoid Hemorrhage
Panel Discussion
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Subarachnoid Hemorrhage Variants
A. PerimesencephalicB. CorticalC. DiffuseD. Intraventricular
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Aneurysmal SAH
What aneurysm locations are most concerning?
Least concerning?
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Patient 1: Diagnostic Testing
66yoF
PMHx of colitis and irritable bowel syndrome
Presented to OSH 5 day history of nausea/vomiting/diarrhea and
abdominal pain, admitted for colitis flare.
Day 3 developed a sudden headache described as a thunderbolt.
Neurological examination is within normal limits.
CT head negative
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CTA demonstrated 3 mm Rt MCA bifurcation aneurysm
LP negative for Xanthochromia
What is the sensitivity of these tests?
Does she need more testing?
Patient 1: Diagnostic Testing
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Patient 1: Diagnostic Testing
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Patient 2: Aneurysm LocalizationWhere is the culprit
aneurysm?
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Patient 2: Aneurysm Localization
Which lesion likely bled, and why?
Are there other tests that would inform the question?
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Patient 2: Aneurysm Localization
Treated AComm with coiling, following MCA for delayed
treatment
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Aneurysm Follow-Up
What follow-up is required for unruptured aneurysms?
What follow-up is required for treated aneuryms?
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Aneurysm Follow-Up After Endovascular Treatment
Catheter angiography at 6 monthsIf occluded at 6 months
recurrence later is 4 mm)
AngioTargeted vs. full angiogram?Time intervals?
MRACE possibly > TOF3T scanners >1.5T
MGH protocol 1yr MRA, then 3,5 and 10 year full angiograms
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Patient 3: Rebleeding
65yoF with ruptured Acomm aneurysm has EVD placed uneventfully.
1 hour later vomits, becomes obtunded.
Post-EVD head CT 1 Hour Post-EVD head CT
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Patient 3: Rebleeding
What factors predict rebleeding?
Is there a role for antifibrinolytics?
What role do EVDs play in rebleeding?
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Patient 4: Treatment Indications
• 68 y.o. F
• Prior history of ruptured distal Lt MCA aneurysm clipped in
2006 outside Massachusetts (with hemicrani and cranioplasty).
• Underwent follow-up imaging which demonstrated a 4 mm AComm
not previously seen
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Should this be treated?
Why?
How should this be treated?
Patient 4: Treatment Indications
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Patient 4: Treatment Indications
Treated with flow diversion using LVIS Blue stent
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Patients 5,6: Blister Aneurysms
What are the challenges of this entity?
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Patients 5,6: Blister Aneurysms
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Dual Antiplatelet Therapy
Who requires it?
What are procedural antiplatelet and anticoagulation
considerations?
How long should therapy continue?
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Patient 7: Vasospasm
Patient transferred with multifocal strokes
Thunderclap headache 10 days prior
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Patient 7: Vasospasm
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Patient 7: Vasospasm
LP negative for xanthochromia
OSH CT and MRI brain negative
Subsequent history of second thunderclap headache and marijuana
use
What is diagnosis?
What are differentials here?
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Patient 8: SAH Variant
59yo F
WHOL over 2 mins, with nausea and vomiting, no LOC
Sleepy, otherwise intact
CTA negative
What is the likely diagnosis?
What is her prognosis?
