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SAH

Sub arachnoid haemorrhage

Deni&on
Subarachnoid haemorrhage is dened as bleeding into the subarachnoid space within the intracranial vault.

Review of anatomy

Incidence
9.1 per 100,000 annually Risk increases in older age - 60% higher in age above 80 Risk of SAH is rela&vely higher in women over 55 years than men

Risk factors
Race Sex Age Gene&cs Smoking Alcohol

E&ology
Head trauma Intra cranial aneurysm Increased blood pressure Increased blood ow Blood vessel disorders Gene&c Infec&ous

Types of aneurysm
Berry (saccular)aneurysm Giant (fusiform) aneurysm Myco&c aneurysm Charcot Bouchard aneurysm Trauma&c aneurysm

Types of aneurysm

Loca<on

Pathophysiology
Mass eect Rupture eect Rupture of cerebral aneurysm Bleeding into subarachnoid space Stroke syndrome develops Increased ICP

Clinical features
Symptoms: Sudden severe headache with or without LOC Associated with vomi&ng, photophobia, drowsiness, restlessness and agita&on Some &me - low back pain and bilateral radicular leg pain (Spinal SAH)

Signs: Neck s&ness Impaired level of consciousness in some pa&ents Subhyaloid haemorrhage (op&c fundus)

Kernigs sign

Brudzinskis sign

Cranial nerve III palsy

Grading of SAH Hunt-Hass classica&on


Category Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Criteria Asymptoma&c or mild headache Moderate-to-severe headache, nuchal rigidity, and no neurological decit other than possible cranial nerve palsy

Mild altera&on in mental status (confusion, lethargy), mild focal neurological decit Stupor and/or hemi paresis Comatose and/or decerebrate rigidity

Diagnos<c procedures
Computed tomography Lumbar puncture Cerebral angiography

Angiography

Complica<ons
Re-bleeding Hydrocephalus Intraventricular haemorrhage Increased intracranial pressure Intracerebral hemorrhage Seizures Cerebral vasospasm

Management
Medical management: Acute care : If pa&ent is comatose - ven&lator assistance ABG analysis Emergency CT scan Cardiac monitoring Pain management

The goal of treatment : to prevent re bleeding and cerebral vasospasm Re bleeding Bed rest Recombinant ac&vator factor VII

Surgical management Clipping of aneurysm

Coiling of aneurysm

Vasospasm

Steroids An&hypertensive An&pyre&cs An&convulsants Analgesics Seda&ves Stool soceners

Respiratory complica&on Venous complica&on Cardiovascular complica&on Fluid and electrolyte disturbance Gastrointes&nal complica&on

Summary
Deni&on Incidence Risk factors E&ology Types Pathophysiology Clinical manifesta&on Management Complica&on