Subarachnoid Subarachnoid HemorrhageHemorrhage

subarachnoid space

ventricles

Incidence of Incidence of Aneurysmal SAHAneurysmal SAHStudies suggest that the incidence in Studies suggest that the incidence in the USA and Europe is 10 to 11 cases the USA and Europe is 10 to 11 cases per 100,000 population per yearper 100,000 population per year

Overall, less than 2% of the entire Overall, less than 2% of the entire population will have an aneurysm; an population will have an aneurysm; an intracranial aneurysm will rupture in intracranial aneurysm will rupture in less than 1% of the population and less than 1% of the population and will be the cause of death in 0.5%will be the cause of death in 0.5%

Age and the Incidence of Age and the Incidence of Aneurysmal SAHAneurysmal SAH

Aneurysmal rupture is extremely Aneurysmal rupture is extremely rare in the first decade of liferare in the first decade of life

Incidence gradually increases each Incidence gradually increases each decade and peaks in the sixth decade and peaks in the sixth decadedecade

Gender and the Gender and the Incidence of Aneurysmal Incidence of Aneurysmal SAHSAHThere is a clear female preponderance There is a clear female preponderance overall; the ratio of females to males overall; the ratio of females to males is 1.6: 1is 1.6: 1

Before age 40 males and females were Before age 40 males and females were equally affected; after age 40 there equally affected; after age 40 there is an increasingly strong is an increasingly strong predominance of femalespredominance of females

Natural HistoryNatural HistoryPrognosis for Surgically Untreated SaccularPrognosis for Surgically Untreated SaccularIntracranial AneurysmsIntracranial Aneurysms

OVERVIEWOVERVIEW

Highest mortality occurs immediately after Highest mortality occurs immediately after the hemorrhage and then decreases rapidlythe hemorrhage and then decreases rapidly

Rebleeding is estimated to occur in 50% of Rebleeding is estimated to occur in 50% of ruptured aneurysms within 6 months of the ruptured aneurysms within 6 months of the first hemorrhage, and afterwards at 3% per first hemorrhage, and afterwards at 3% per yearyear

50-60%50-60% of patients die after rebleeding and of patients die after rebleeding and 25% are left disabled25% are left disabled

Mortality at 1 day was 32%Mortality at 1 day was 32%

Mortality at 1 week was 43%Mortality at 1 week was 43%

Mortality at 1 month was 56%Mortality at 1 month was 56%

Mortality at 6 months was 60%Mortality at 6 months was 60%

Clinical presentationsClinical presentations

A lot of symptoms with minimal signsA lot of symptoms with minimal signs::

11--severe thunder clump headachesevere thunder clump headache

22--repeated projectile vomitingrepeated projectile vomiting

33--photophobiaphotophobia

44--meningeal signsmeningeal signs

55--papilodema +/- subhyloid Hmpapilodema +/- subhyloid Hm

Clinical Grading Scales for Clinical Grading Scales for SAHSAH

Grade DescriptionGrade Description

Hunt and Hess ScaleHunt and Hess Scale

11 Asymptomatic or minimal headache and slight nuchal Asymptomatic or minimal headache and slight nuchal rigidityrigidity

22 Moderate to severe headache, nuchal rigidity, no Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsyneurological deficit other than cranial nerve palsy

33 Drowsiness, confusion, or mild focal deficitDrowsiness, confusion, or mild focal deficit

44 Stupor, moderate to severe hemiparesis, possible Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbancesearly decerebrate rigidity and vegetative disturbances

55 Deep coma, decerebrate rigidity, moribund Deep coma, decerebrate rigidity, moribund appearanceappearance

Clinical Grading Scales for Clinical Grading Scales for SAH SAH .../cont’d.../cont’d

Grade DescriptionGrade Description

World Federation of Neurological Surgeons World Federation of Neurological Surgeons ScaleScale

11 Glasgow coma scale 15, no motor deficitGlasgow coma scale 15, no motor deficit

22 GCS 13 to 14, no motor deficitGCS 13 to 14, no motor deficit

33 GCS 13 to 14, with motor deficitGCS 13 to 14, with motor deficit

44 GCS 7 to 12, with or without motor deficitGCS 7 to 12, with or without motor deficit

55 GCS 3 to 6, with or without motor deficitGCS 3 to 6, with or without motor deficit

Diagnosis of Subarachnoid Diagnosis of Subarachnoid

HemorrhageHemorrhage ((

Headaches accounts for 1-2% of Headaches accounts for 1-2% of visits to ER; 1% of theses have visits to ER; 1% of theses have SAHSAH

About 80% of patients with About 80% of patients with nontraumatic SAH have a ruptured nontraumatic SAH have a ruptured saccular aneurysm; of the other saccular aneurysm; of the other 20%, about 1/2 have 20%, about 1/2 have nonaneurysmal perimesencephalic nonaneurysmal perimesencephalic hemorrhageshemorrhages

••The first diagnostic test should be The first diagnostic test should be non-contrast CT scanningnon-contrast CT scanning

••Timing of the CT scan in relation to Timing of the CT scan in relation to SAH ictus is important; positive SAH ictus is important; positive results decrease with time; 98-results decrease with time; 98-100% are positive up to 12 hours 100% are positive up to 12 hours after the ictus and 93% are positive after the ictus and 93% are positive in the first 24 hoursin the first 24 hours

Diagnosis of Subarachnoid Hemorrhage .../cont’d

LP should be performed in patients whose LP should be performed in patients whose clinical presentation suggests SAH and clinical presentation suggests SAH and whose CT is negativewhose CT is negative

‘‘Traumatic Tap’ occurs in up to 20% of LPs; Traumatic Tap’ occurs in up to 20% of LPs; Released hemoglobin is metabolized to the Released hemoglobin is metabolized to the pigmented molecular oxyhemoglobin pigmented molecular oxyhemoglobin (reddish pink) and bilirubin (yellow), resulting (reddish pink) and bilirubin (yellow), resulting in xanthochromia. Oxyhemoglobin can be in xanthochromia. Oxyhemoglobin can be detected within hours, but the formation of detected within hours, but the formation of

bilirubin requires up to 12 hours to occurbilirubin requires up to 12 hours to occur . .

Diagnosis of Subarachnoid Hemorrhage .../cont’d

cathetercatheterarteriographyarteriography

anterioranteriorcirculationcirculation

posteriorposteriorcirculationcirculation

CT scan of a subarachnoid hemorrhage (SAH)

Treatment:Treatment:the aim of the treatment isthe aim of the treatment isto prevent a new rupture of the aneurysmto prevent a new rupture of the aneurysm

options:options:Medical non aneurysmal or surgery is contraindication Medical non aneurysmal or surgery is contraindication

surgical surgical clip or endovascular coilsclip or endovascular coils

Medical treatmentMedical treatment

11--Complete rest, sedation, keep the Complete rest, sedation, keep the patient in dark roompatient in dark room

22--AnalgesicAnalgesic

33--IV fluid (2/3 of the requirement)IV fluid (2/3 of the requirement)

44--Nimodipine 60mg every 4hoursNimodipine 60mg every 4hours

55--LaxativeLaxative

66--Control the BPControl the BP

clipclipopen surgeryopen surgery

where is the aneurysm?where is the aneurysm?

SAHSAH

where is the aneurysm?where is the aneurysm?

surgical clipsurgical clip

beforebefore afterafter

coilscoilsendovascular treatmentendovascular treatment

SAHSAH

rupture of an aneurysm rupture of an aneurysm at the tip of the basilar at the tip of the basilar arteryartery

beforebefore afterafter