Subarachnoid hemorrhage: Difference between revisions
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* "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