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 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
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