Management of Subarachnoid HemorrhageGregory W Balturshot, M.D.

Central Ohio Neurological SurgeonsMay 24, 2013

Introduction

• Risk factors - hypertension, smoking, cocaine, female gender, age >50

• Genetic risk factors - Moya Moya, Ehlers-Danlos, PCKD, Marfan’s, fibrimuscular dysplasia

Clinical Presentation

• 80% describe the sudden onset of worst headache on my life

• 20% experience ‘sentinal headache’ 2-8 weeks before SAH

• other symptoms include photophobia, nausea and vomiting, seizures, loss of consciousness

Hunt Hess Scale

Fisher Grade

Diagnosis• Noncontrast CT - sensitivity 92-95%

• Lumbar Puncture - Xanthrochromia may take 12 hrs to appear after initial SAH. differentiates from a ‘traumatic tap’

• MRI/MRA - sensitivity 55-93% for aneurysms >5mm it is 85-100%

• CTA - 77-100% and 85-100%. Additional information such as wall calcification, intraluminal thrombus, relationship to the clinoids

Gold standard is angiogram

Initial Critical Care Management

• Stablization of systemic oxygenation/hemodynamics

• ICP control

• BP control

• Seizure prophylaxis

• Prevention of aneurysm rebleeding (9-17% within 72hrs)

Clip vs Coil• ISAT - International subarachnoid

aneurysm trial

• 2134 good grade patients with <10 mm aneurysms in the anterior circulation were randomized to clipping or coiling.

• Death and dependency @ 1 yr 23.5% vs 30.9%

• Rebleeding rates?

Clip vs Coil

• TEAM approach

• Factors include the clinical state of the patient, anatomic location, neck to dome ratio (wide neck), hematoma with mass effect