Diagnosis and Management of Subarachnoid Hemorrhage

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  • 8/18/2019 Diagnosis and Management of Subarachnoid Hemorrhage


    Diagnosis and Management of Subarachnoid Hemorrhage

    Jose I. Suarez, MD, FNCS, FANA


    Purpose of Review: The purposeof this article is to present the epidemiology, clinical presentation, and management of patients with subarachnoid hemorrhage (SAH). SAH is a neurologic emergency that carries high morbidity and mortality. Patients with SAH are at risk for several significant neurologic complications, including hydrocephalus, ce- rebral edema, delayed cerebral ischemia, rebleeding, seizures, and neuroendocrine ab- normalities that lead to impaired body regulation of sodium, water, and glucose. Recent Findings:  The incidence of SAH has remained stable, but mortality of hos- pitalized patients has significantly declined over the past 3 decades. Many common therapies for SAH have created controversy, and various recent neuroprotective clinical trials have produced negative results. However, the publication of two consensus guide- lines by theAmerican Heart Association/American StrokeAssociation and theNeurocritical Care Society have provided a clarification for what should constitute best practice for patients with SAH. The most important of those recommendations include the fol- lowing: admission of patients to high-volumecenters(defined as more than 35 patients with SAH per year) under the management of a specialized and multidisciplinary team;

    early identification and management of the bleeding source; evaluation and treatment decision for unsecured aneurysms by a multidisciplinary team made up of cerebrovas- cular neurosurgeons, endovascular practitioners, and neurointensivists; management of patients in the neurocritical care unit with oral nimodipine, blood pressure control, euvolemia, and frequent monitoring for neurologic and systemic complications; and delayed cerebral ischemia secondary to cerebral vasospasm should be treated with induced hypertension and endovascular therapies once confirmed. Summary:   SAH is a devastating neurologic disease. Management of patients with SAH should adhere to currently available treatment guidelines. Several aspects of SAH man- agement remain controversial and need further studies to clarify their role in improving patient outcome.

    Continuum (Minneap Minn) 2015;21(5):1263–1287.


    Nontraumatic subarachnoid hemor- rhage (SAH) represents about 3% of  all strokes in the United States.1 The

     worldwide incidence of SAH ranges from 2 to 16 per 100,000 people and has not changed in the past 3 decades.2

    Most epidemiologic studies have shown

    that women are more likely to have SAH compared to men (1.24:1.0) and that minority groups (particularly African

     American and Hispanic populations) are more frequently affected compared to white Americans.1,2 The incidence of SAH increases with age, with a typi- cal mean age of onset of 50 years or 

     Address correspondence to Dr Jose I. Suarez, Baylor  College of Medicine, One Baylor Plaza, NB:302, Houston, TX 77030,  jisuarez@bcm.edu.

    Relationship Disclosure: Dr Suarez reports no disclosure.

    Unlabeled Use of  Products/Investigational  Use Disclosure: Dr Suarez reports no disclosure.

    *   2015, American Academy  of Neurology.

    1263Continuum (Minneap Minn) 2015;21(5):1263–1287 www.ContinuumJournal.com

    Review Article

    Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

    mailto:jisuarez@bcm.edu mailto:jisuarez@bcm.edu

  • 8/18/2019 Diagnosis and Management of Subarachnoid Hemorrhage


    older.2 In about 80% of SAH cases, a ruptured cerebral aneurysm is found.

    However, neuroimaging techniques may show no source of bleeding in 15% of SAH cases or show other abnormali- ties (eg, arteriovenous malformation,

     vasculitis) in the remaining 5% of cases. SAH causes significant morbidity and

    mortality. Mortality rates vary widely  among studies, ranging from 8% to 67% (median of 30% in the United States),

     with the caveat that most of these studies did not account fully for prehospital deaths, which have been estimated to

    be between 10% and 15%.


    However,there has been a significant decrease in case-fatality rates of SAH across the globe,3  which has been attributed to im- proved survival of hospitalized patients and is most likely owing to changes in management of patients with SAH, in- cluding neurocritical care, endovascular  therapy, and more refined microsurgical techniques. Nevertheless, it is important to emphasize that despite the decrease in case-fatality rates, about half of survi-

     vors experience significant chronic reduc-

    tions in health-related quality of life.4,5 For example, a large proportion of survi-

     vors do not return to their previous level of employment, social independence and interactions, or personal or family rela- tionships even 5 years after the event. This reduction in health-related qual- ity of life may be due to a combination of factors, including impaired physical functioning, cognitive deficits (partic- ularly executive function and memory), mood and emotional symptoms (eg, an-

     xiety, depression, and posttraumaticstress disorder), and personality changes. Several risk factors for SAH have been

    identified ( Table 1-1 ).2,6 Y 10  Whether  any of these factors plays a predominant role in an individual patient remains un- clear. Genetic and environmental fac- tors also can increase the risk of SAH, and some of these factors can interact. For instance, the size at which cerebral

    aneurysms rupture may be smaller for  those patients with concomitant hyper-

    tension and cigarette smoking than for  those with either factor alone.

    SAHremains one of the topneurologic emergencies, and neurologists must fa- miliarize themselves with this devastating disease. This review discusses the main features of diagnosis and management of  SAH. The main areas of emphasis when caring for patients with SAH should in- clude the following: prompt evaluation and diagnosis,11 immediate transfer to appropriate centers,2,12 expeditious di-

    agnosis and treatment of the bleedingsource,13,14 and overall good neurocrit- ical care adhering to available treat- ment guidelines.2,12


    SAH typically presents with sudden and severe headache (usually described as ‘‘the worst headache ever’’) accompa- nied by nausea, vomiting, photophobia, neck pain, and loss of consciousness ( Case 1-1A  ).15 Physical examination should include determination of level

    of consciousness, funduscopic evalua- tion, determination of meningeal signs, and presence of focal neurologic defi- cits ( Table 1-2 ). The latter are present in about 10% of patients with SAH and are associated with worse prognosis when due to the presence of thick subarach- noid clot or parenchymal hemorrhage. Transient elevation in the intracranialpres- sure (ICP) causes nausea, vomiting, and syncope. However, more sustained and severe increases in ICP can lead to coma

    and brain death. Terson syndrome (vit-reous hemorrhage associated with SAH) can present in up to 40% of patients

     with SAH.16,17 The sudden spike in ICP is thought to lead to preretinal hemor- rhages, which are associated with more severe SAH and increased mortality.

    Some patients with SAH can have a more atypical presentation.11,15 Occasion- ally, patients may present with seizures,


    h Subarachnoid hemorrhage

    is more frequent in

    women than men and

    more frequent in

    minority populations

    compared to

    white Americans.

    h Case-fatality rates of

    hospitalized patients

    with subarachnoid

    hemorrhage have

    decreased with the

    advent of neurocriticalcare,

    endovascular therapy,

    and more refined

    microsurgical techniques.

    h The most important

    points in the management

    of patients with

    subarachnoid hemorrhage

    are prompt evaluation

    and diagnosis, immediate

    transfer to appropriate

    centers, expeditious

    diagnosis andtreatment of

    the bleeding source, and

    overall good neurocritical

    care adhering to available

    treatment guidelines.

    1264   www.ContinuumJournal.com October 2015

    Subarachnoid Hemorrhage

    Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

  • 8/18/2019 Diagnosis and Management of Subarachnoid Hemorrhage


    TABLE 1-1   Risk Factors for Subarachnoid Hemorrhage

    b  Nonmodifiable Risk Factors


    Female sex

    Prior history of aneurysmal subarachnoid hemorrhage

    Family history of subarachnoid hemorrhage

    History of aneurysm in first-degree relatives (especially in two or more relatives)

    b  Modifiable Risk Factors


    Cigarette smoking

    Heavy alcohol use

    Sympathomimetic drug use (eg, cocaine)

    b  Other

    Certain genetic disorders (eg, autosomal dominant polycystic kidney disease, type IV Ehlers-Danlos syndrome)

    Anterior circulation aneurysms are more likely to rupture in patients who are younger than 55 years of age

    Posterior circulation aneurysms are more likely to rupture in men

    Significant financial or legal problems within the past 30 days

    Cerebral aneurysms of more than 7 mm in diameter

    Case 1-1A A 45-year-old right-handed woman presented to a primary stroke center with