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Presented at the Second Neurosurgical MasterClass, Cluj-Napoca, 2014.
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Subarachnoid Hemorrhage(SAH)
Ionuţ Cărăvan Coordinated by Prof. Ioan Ştefan Florian, MD, PhD
University of Medicine and Pharmacy “Iuliu Haţieganu“ Cluj Napoca
Definition
• SAH = extravasation of blood into the subarachnoid space
Etiology
Greenberg Handbook of Neurosurgery, 2010
Traumatic SAH Non-traumatic (spontaneous) SAH
o ruptured intracranial aneurysms (75 %)oAVM (5 %)oothers (tumor, vasculitis, coagulation disorders, dural
sinus thrombosis)ounknown etiology (15 %)=“angiogram-negative SAH”
Presenting features(1)
• HEADACHE (“thunderclap headache”)• meningismus
neck stiffness photophobia back pain
Presenting features(2)
• decreased state of consciousness• nausea and vomiting• seizures• focal neurologic deficits:
oculomotor palsy hemiparesis
• ocular hemorrhage
Radiographic findings
• CT scan• Cerebral Angiography• FLAIR* MRI• CT Angiography• MRA**
*Fluid-attenuated inversion recovery**Magnetic Resonance Angiography
CT scan
Lumbar puncture
Grading SAH
Hunt and Hess Grade WFNS* Grading
*World Federation of Neurological Surgeons
Complications
• Hydrocephalus• Vasospasm => delayed cerebral ischemia • Seizures• Rebleeding• Intracerebral hemorrhage• Intraventricular hemorrhage• Left ventricular systolic dysfunction• Subdural hematoma
Treatment
• BP control (fluid restriction and antihypertensive therapy) when the mean arterial pressure exceeds 130 mm Hg
• ICP control (osmotic agents, loop diuretics)
• Symptomatic treatment: – anticonvulsants: levetiracetam, phenytoin– analgesics: fentanyl– anti-emetics: odansetron– calcium channel blockers: nimodipine, verapamil => vasospasm
!!! Prevention of rebleeding:
• antifibrinolytic therapy • surgical treatment • endovascular treatment
References
• MS Greenberg. Handbook of Neurosurgery. Seventh Edition. New York: Thieme Medical Publishers; 2010.
• AH Kaye. Essential Neurosurgery. Third Edition. Oxford: Blackwell Publishing Ltd; 2005.
• MG Yasargil. Microneurosurgery. New York: Thieme Medical Publishers Inc; 1994.
Thank you!