Subarachnoid hemorrhage: Difference between revisions

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== Definition ==
==Background==


* Life-threatening intracerebral hemorrhage occurring below the arachnoid membrane
*Life-threatening intracerebral hemorrhage occurring below the arachnoid membrane


== Epidemiology ==
===Epidemiology===


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


== WFNS Grade (Clinical) ==
===WFNS Grade (Clinical)===
{| class="wikitable"
!Grade
!GCS
!Deficits
|-
|I
|15
|no motor deficits
|-
|II
|13-14
|no motor deficits
|-
|III
|13-14
|motor deficits
|-
|IV
|7-12
| +/- motor deficits
|-
|V
|3-6
| +/- motor deficits
|}


===Fisher Grade (Radiological)===
* I -- GCS 15, no motor deficit
{| class="wikitable"
* II -- GCS 13-14, no motor deficit
!Grade
* III -- GCS 13-14, motor deficit
!Findings
* IV -- GCS 7-12 +/- motor deficit
|-
* V -- GCS 3-6, motor deficit present or absent
|I
|no blood
|-
|II
|diffuse deposition of SAG without clots or layers of blood >1 mm
|-
|III
|localized clots and/or vertical layers of blood >1 mm thick
|-
|IV
|diffuse or no subarachnoid blood but intracerebral or intraventricular clots
|}


===Etiology===
== Fisher Grade (Radiological) ==


*'''Trauma''' (most common)
* I -- no blood
*'''Intracranial aneurysms''' (80% of spontaneous SAH)
* II -- diffuse deposition of SAH without clots or layers of blood >1mm
**AComm most common
* III -- localized clots and/or vertical layers of blood 1mm or > thickness
**PComm second-most common
* IV -- diffuse or no subarachnoid blood but intracerebral or intraventricular clots
*Non-aneurysmal perimesencephalic hemorrhage
*Arteriovenous malformations
*Arterial dissection and CNS vasculitis
*Coagulopathies
*Drug-induced
**Cocaines
**Amphetamines
*Pituitary apoplexy


== Etiology ==
===Locations===


*Basal ganglia and thalamus are more likely to be hypertension-related
* '''Trauma''' (most common)
*Cerebellum
* '''Intracranial aneurysms''' (80% of spontaneous SAH)
*Lobar is more likely to be amyloid
** AComm most common
*Pontine
** PComm second-most common
* Non-aneurysmal perimesencephalic hemorrhage
* Arteriovenous malformations
* Arterial dissection and CNS vasculitis
* Coagulopathies
* Drug-induced
** Cocaines
** Amphetamines
* Pituitary apoplexy


== Locations ==
===Risk factors===


*'''Smoking''' (RR 10-20)
* Basal ganglia and thalamus are more likely to be hypertension-related
*Hypertension and alcohol abuse
* Cerbellum
*Family history of polycystic kidney disease or connective tissue disorders
* Lobar is more likely to be amyloid
* Pontine


==Clinical Manifestations==
== Risk factors ==


*"Thunderclap headache"/"worst headache of my life"
* '''Smoking''' (RR 10-20)
**Peaks in minutes
* Hypertension and alcohol abuse
**May have occurred with exertion (50%) or in sleep (15-30%)
* Family history of polycystic kidney disease or connective tissue disorders
*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


== Screening ==
==Investigations==


*CT head
* Generally not recommended unless strong family history
*+/- lumbar puncture
* Treat if >10mm


==Management==
== Clinical Presentation ==


*Initial management
* "Thunderclap headache"/"worst headache of my life"
**Stabilize patient (ABCs)
** Peaks in minutes
**Send for CT head +/- LP to confirm diagnosis
** May have occurred with exertion (50%) or in sleep (15-30%)
**Consult neurosurgery
* Soon after onset
*Stabilization
** +/- nausea & vomiting
**Ensure IV access
** +/- transient loss of consciousness or weakness
**Manage airway, with intubation if necessary
* Sentinel bleed with warning headache in 20-50%
**Cardiac monitoring (arrhythmias are common)
* May present with seizures
**Bed rest, elevate head of bed to 30 degrees
* Other signs
**Pneumatic compression devices for thromboembolism prophylaxis
* Reduced of altered level of consciousness (30%)
**Adequate fluid intake
* Intraocular hemorrhage (20-40%)
**Blood pressure control
** Presence of subhyaloid hemorrhage pathognomonic
***Goal: SBP <160 (now <140) or less and MAP <110
* Cranial nerve palsies
***Be aggressive, using IV labetalol, hydralazine, enalapril
** Especially oculomotor (PComm aneurysm)
*Vasospasm prophylaxis: nimodipine 60mg po q4h for 21 days
* Meningismus, after a few hours (from blood breakdown)
*Treat coagulopathies
* Focal deficits
*After transfer to tertiary centre
** Hemiparesis possible if intracerebral clot (e.g. MCA)
**Serial CT or CT angiogram
* Systemic features
**Angiogram when available
** Fever, hypertension, arrhythmias/EKG changes
**Surgical clipping or endovascular coiling by neurosurgery or interventional radiology
* Paramesencephalic subarachnoid hemorrhage
** More benign, small aneurysm that self-resolves
** Two negative angiograms separated by 10-14 days


==Complications==
== Investigations ==


*Vasospasm
* CT head
**Onset at 3-5 days, peak at 1-2 weeks
* +/- lumbar puncture
**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


== Management ==
==Prognosis==


*10% died before hospital, usually from arrhythmias or acute hydrocephalus
* Initial management
*10% die in first 24h, usually from early rebleeding
** Stabilize patient (ABCs)
*Long-term survival less than 50%
** Send for CT head +/- LP to confirm diagnosis
**1/2 will never return to previous quality of life
** 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 ==
== Prevention ==


=== Screening ===
* 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


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

* 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:Neurology]]

Latest revision as of 13:15, 4 September 2020

Background

  • 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)

Grade GCS Deficits
I 15 no motor deficits
II 13-14 no motor deficits
III 13-14 motor deficits
IV 7-12 +/- motor deficits
V 3-6 +/- motor deficits

Fisher Grade (Radiological)

Grade Findings
I no blood
II diffuse deposition of SAG without clots or layers of blood >1 mm
III localized clots and/or vertical layers of blood >1 mm thick
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
  • Cerebellum
  • 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

Clinical Manifestations

  • "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

Prevention

Screening

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