Subarachnoid hemorrhage: Difference between revisions
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m (Text replacement - "== Clinical Presentation" to "== Clinical Manifestations") |
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− | == |
+ | ==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)=== |
+ | {| 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 |
||
− | == |
+ | ===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 |
||
− | == |
+ | ===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 |
||
− | == |
+ | ==Investigations== |
+ | *CT head |
||
− | * Generally not recommended unless strong family history |
||
+ | *+/- lumbar puncture |
||
− | * Treat if >10mm |
||
+ | ==Management== |
||
− | == Clinical Manifestations == |
||
+ | *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 |
||
− | == |
+ | ==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 |
||
− | == |
+ | == 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 09:15, 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