Subarachnoid Hemorrhage

subarachnoid space ventricles

Incidence of Aneurysmal SAH Studies suggest that the incidence in the USA and Europe is 10 to 11 cases per 100,000 population per year Overall, less than 2% of the entire population will have an aneurysm; an intracranial aneurysm will rupture in less than 1% of the population and will be the cause of death in 0.5%

Age and the Incidence of Aneurysmal SAH Aneurysmal rupture is extremely rare in the first decade of life Incidence gradually increases each decade and peaks in the sixth decade

Gender and the Incidence of Aneurysmal SAH There is a clear female preponderance overall; the ratio of females to males is 1.6: 1 Before age 40 males and females were equally affected; after age 40 there is an increasingly strong predominance of females

Natural History Prognosis for Surgically Untreated Saccular Intracranial Aneurysms OVERVIEW Highest mortality occurs immediately after the hemorrhage and then decreases rapidly Rebleeding is estimated to occur in 50% of ruptured aneurysms within 6 months of the first hemorrhage, and afterwards at 3% per year 50-60% of patients die after rebleeding and 25% are left disabled

Mortality at 1 day was 32% Mortality at 1 week was 43% Mortality at 1 month was 56% Mortality at 6 months was 60%

Clinical presentations A lot of symptoms with minimal signs: 1-severe thunder clump headache 2-repeated projectile vomiting 3-photophobia 4-meningeal signs 5-papilodema +/- subhyloid Hm

Clinical Grading Scales for SAH Grade Description Hunt and Hess Scale 1 Asymptomatic or minimal headache and slight nuchal rigidity 2 Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy 3 Drowsiness, confusion, or mild focal deficit 4 Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbances 5 Deep coma, decerebrate rigidity, moribund appearance

Clinical Grading Scales for SAH.../cont ’ d Grade Description World Federation of Neurological Surgeons Scale 1 Glasgow coma scale 15, no motor deficit 2 GCS 13 to 14, no motor deficit 3 GCS 13 to 14, with motor deficit 4 GCS 7 to 12, with or without motor deficit 5 GCS 3 to 6, with or without motor deficit

Diagnosis of Subarachnoid Hemorrhage ( Headaches accounts for 1-2% of visits to ER; 1% of theses have SAH About 80% of patients with nontraumatic SAH have a ruptured saccular aneurysm; of the other 20%, about 1/2 have nonaneurysmal perimesencephalic hemorrhages

The first diagnostic test should be non- contrast CT scanning The first diagnostic test should be non- contrast CT scanning Timing of the CT scan in relation to SAH ictus is important; positive results decrease with time; % are positive up to 12 hours after the ictus and 93% are positive in the first 24 hours Timing of the CT scan in relation to SAH ictus is important; positive results decrease with time; % are positive up to 12 hours after the ictus and 93% are positive in the first 24 hours Diagnosis of Subarachnoid Hemorrhage.../cont’d

LP should be performed in patients whose clinical presentation suggests SAH and whose CT is negative ‘ Traumatic Tap ’ occurs in up to 20% of LPs; Released hemoglobin is metabolized to the pigmented molecular oxyhemoglobin (reddish pink) and bilirubin (yellow), resulting in xanthochromia. Oxyhemoglobin can be detected within hours, but the formation of bilirubin requires up to 12 hours to occur. Diagnosis of Subarachnoid Hemorrhage.../cont’d

catheterarteriography

anteriorcirculation

posteriorcirculation

CT scan of a subarachnoid hemorrhage (SAH)

Treatment: the aim of the treatment is to prevent a new rupture of the aneurysm options: Medical non aneurysmal or surgery is contraindication surgical clip or endovascular coils

Medical treatment 1-Complete rest, sedation, keep the patient in dark room 2-Analgesic 3-IV fluid (2/3 of the requirement) 4-Nimodipine 60mg every 4hours 5-Laxative 6-Control the BP

clip open surgery

where is the aneurysm? SAH

surgical clip

beforeafter

coils endovascular treatment

SAH rupture of an aneurysm at the tip of the basilar artery

beforeafter