Aidan at 13:15, 4 September 2020

2020-09-04T13:15:59Z

Aidan: Text replacement - "== Clinical Presentation" to "== Clinical Manifestations"

2020-08-02T10:56:23Z

Text replacement - "== Clinical Presentation" to "== Clinical Manifestations"

← Older revision		Revision as of 10:56, 2 August 2020
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	* Treat if >10mm		* Treat if >10mm

	== Clinical ~~Presentation~~ ==		== Clinical Manifestations ==

	* "Thunderclap headache"/"worst headache of my life"		* "Thunderclap headache"/"worst headache of my life"

Maintenance script: Imported from text file

2020-07-04T01:17:57Z

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== Definition ==

* Life-threatening intracerebral hemorrhage occurring below the arachnoid membrane

== Epidemiology ==

* Incidence of 10-14 per 100,000 persons / year
** Accounts for 3-5% of all strokes
* More common in women
* About 1% of population has an asymptomatic intracranial aneurysm

== WFNS Grade (Clinical) ==

* I -- GCS 15, no motor deficit
* II -- GCS 13-14, no motor deficit
* III -- GCS 13-14, motor deficit
* IV -- GCS 7-12 +/- motor deficit
* V -- GCS 3-6, motor deficit present or absent

== Fisher Grade (Radiological) ==

* I -- no blood
* II -- diffuse deposition of SAH without clots or layers of blood >1mm
* III -- localized clots and/or vertical layers of blood 1mm or > thickness
* IV -- diffuse or no subarachnoid blood but intracerebral or intraventricular clots

== Etiology ==

* '''Trauma''' (most common)
* '''Intracranial aneurysms''' (80% of spontaneous SAH)
** AComm most common
** PComm second-most common
* Non-aneurysmal perimesencephalic hemorrhage
* Arteriovenous malformations
* Arterial dissection and CNS vasculitis
* Coagulopathies
* Drug-induced
** Cocaines
** Amphetamines
* Pituitary apoplexy

== Locations ==

* Basal ganglia and thalamus are more likely to be hypertension-related
* Cerbellum
* Lobar is more likely to be amyloid
* Pontine

== Risk factors ==

* '''Smoking''' (RR 10-20)
* Hypertension and alcohol abuse
* Family history of polycystic kidney disease or connective tissue disorders

== Screening ==

* Generally not recommended unless strong family history
* Treat if >10mm

== Clinical Presentation ==

* "Thunderclap headache"/"worst headache of my life"
** Peaks in minutes
** May have occurred with exertion (50%) or in sleep (15-30%)
* Soon after onset
** +/- nausea & vomiting
** +/- transient loss of consciousness or weakness
* Sentinel bleed with warning headache in 20-50%
* May present with seizures
* Other signs
* Reduced of altered level of consciousness (30%)
* Intraocular hemorrhage (20-40%)
** Presence of subhyaloid hemorrhage pathognomonic
* Cranial nerve palsies
** Especially oculomotor (PComm aneurysm)
* Meningismus, after a few hours (from blood breakdown)
* Focal deficits
** Hemiparesis possible if intracerebral clot (e.g. MCA)
* Systemic features
** Fever, hypertension, arrhythmias/EKG changes
* Paramesencephalic subarachnoid hemorrhage
** More benign, small aneurysm that self-resolves
** Two negative angiograms separated by 10-14 days

== Investigations ==

* CT head
* +/- lumbar puncture

== Management ==

* Initial management
** Stabilize patient (ABCs)
** Send for CT head +/- LP to confirm diagnosis
** Consult neurosurgery
* Stabilization
** Ensure IV access
** Manage airway, with intubation if necessary
** Cardiac monitoring (arrhythmias are common)
** Bed rest, elevate head of bed to 30 degrees
** Pneumatic compression devices for thromboembolism prophylaxis
** Adequate fluid intake
** Blood pressure control
*** Goal: SBP <160 (now <140) or less and MAP <110
*** Be aggressive, using IV labetalol, hydralazine, enalapril
* Vasospasm prophylaxis: nimodipine 60mg po q4h for 21 days
* Treat coagulopathies
* After transfer to tertiary centre
** Serial CT or CT angiogram
** Angiogram when available
** Surgical clipping or endovascular coiling by neurosurgery or interventional radiology

== Complications ==

* Vasospasm
** Onset at 3-5 days, peak at 1-2 weeks
** Evaluate with transcranial dopplers +/- angiogram, although clinical diagnosis more important that radiological
** Prophylaxis with nimodipine
** Hyperdynamic therapy (3H)
*** Hyperhydration (150-200cc/h)
*** Hypertension (inotropes if necessary)
*** Hemodilution
*** Only after aneurysm is secure
* Hydrocephalus
** May need VP shunt
* EKG changes
** Changes to ST, T, and U
** Prolonged QT (60%)
** Arrhythmias
* Rebleeding
** 50% re-reupture within 6 months
** About 2%/day up to 15-20% at 14 days
** Often fatal
* Seizures
** Can prophylax with phenytoin for 1 week
* Hyponatrmia
** SIADH or cerebral salt wasting (atrial natriuretic protein), depending on volume status
** Avoid hypotonic fluids

== Prognosis ==

* 10% died before hospital, usually from arrhythmias or acute hydrocephalus
* 10% die in first 24h, usually from early rebleeding
* Long-term survival less than 50%
** 1/2 will never return to previous quality of life

[[Category:Neurology]]
[[Category:Critical care]]

Subarachnoid hemorrhage - Revision history

Aidan at 13:15, 4 September 2020

Aidan: Text replacement - "== Clinical Presentation" to "== Clinical Manifestations"

Maintenance script: Imported from text file