Subarachnoid hemorrhage: Difference between revisions

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* Treat if >10mm
   
== Clinical Presentation ==
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== Clinical Manifestations ==
   
 
* "Thunderclap headache"/"worst headache of my life"
 
* "Thunderclap headache"/"worst headache of my life"

Revision as of 05:56, 2 August 2020

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 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