Subarachno

id
Hemorrhag
e
DONE BY : Rawan Alebous

Subarachnoid
hemorrhage is
bleeding in the
space between
arachnoid and pia
matter
Intracranial vessels lie in the
subarachnoid space and
give off small perforating
branches to the brain
tissue . Bleeding from
these vessel or associated
aneurysms occurs
primarily into this space .
Some intracranial
aneurysms are embedded
within the brain tissue and
their bleeding cause

Causes of SAH
The most common causes of SAH after
trauma
Aneurysms -------- 70%
Perimesencephalic hemorrhage -------10%
A-V malformations ------- 5%
Bleeding diathesis
Anticoagulants
------ 5%
Tumors
Vasculitis
Undefined ---------10%

Incidence
- 8-10 per 100000
- Female : male 3:2
- Higher in the 3rd trimester of
pregnancy
- Mean age is 55 yrs old , in
anuerysmal SAH : 40-60

Risk factors

Cigarette smoking
Hypertension
Alcohol
Genetic risk (autosomal dominant polycystic
kidney disease, glucocorticoid-remediable
aldosteronism, and Ehler Danlos syndrome.)
Sympathomimetic drugs (phenylpropanolamine)
Estrogen deficiency
Antithrombotic therapy ( severity)
Statins

Signs and Symptoms

Headache
Severe , sudden
Sometimes the headache is mild but
sudden and this may represent a
warning leak before a major bleed

Signs and Symptoms

Meningism
After 3-12 hours
Neck stiffness

Signs and Symptoms

Nausea
Vomiting
Loss of consciousness or coma
Epileptic seizers

Signs and Symptoms

Focal neurological deficits
e.g. limb weakness , dysphasia
III nerve palsy ( it indicates either
transtentorial herniation or direct
nerve injury from post.
communicating artery aneurysms )

Signs and Symptoms

Fundus examination
Papilledema or vitreous hemorrhage

Signs and Symptoms

- Reactive HTN ( rise of pressure with
no history of HTN and takes several
days )
- Pyrexia (common ,but may indicate
ischemic hypothalamic damage )

Grading

Grading ( fischer scale )

Investigations
CT scan
Confirms the diagnosis in 95% of
cases if within 48 hours of bleeding

Investigations
In CT scan blood may be widely
distributed : throughout basal cisterns ,sylvian and
interhemispheric fissures
- over the cortical sulci
- Within the ventricular system

Investigations
Lumbar puncture
Diagnose subarachnoid hemorrhage
but LP could precipitate
transtentorial herniation in patients
with a mass lesion

Investigations
MRI
not routinely used but with patient
with multiple aneurysms MRI can be
performed several days after the
bleed

Investigations
CT/MR Angiography

Cerebral Aneurysms
Incidence :
2% of the population
Aneurysm rupture occurs in 6-8 per
100000 in a year
Female:male 3:2 , but it varies with
age ;
Before 40 --- males>females
After 40 --- females>males

Cerebral Aneurysms
Risk factors :
Atherosclerotic disease
Family history
Poly cystic kidney disease

Cerebral Aneurysms
Morphology :
Saccular : at vessel bifurcation
Rupture usually occurs at the
fundus of the aneurysm

Cerebral Aneurysms
Fusiform dilatation: rarely rupture
,results from atherosclerosis
Mycotic aneurysms : secondary to
vessel wall infection

Site of saccular aneurysms

Clinical presentation
Rupture- 1

Clinical presentation
2- Compression from aneurysmal sac :

Anterior
communicating
artery aneurysms
may compress the
pituitary stalk or
hypothalamus
causing
hypopituitarism
Or the optic nerve or
chiasma causing
visual field defect

A basilar artery
aneurysm
compress midbrain
, pons or 3rd nerve
causing limb
weakness or
impaired eye
movement

Clinical presentation
Intracavernous
aneurysms
compress 3rd ,
4th , 6th and first
trigeminal
division
producing
opthalmoplegia
and facial pain

A posterior
communicating
artery aneurysm
may produce 3rd
nerve palsy

Clinical presentation
3- Incidental finding

Complications of ruptured
aneurysms
Intracranial
- Re bleeding
- Vasospasm
- Hydrocephalus
- Epilepsy
- hyponatremia

Complications
Re-bleeding
Re-bleeding is a major problem following
SUH . 30% would re-bleed in the first 28
day
The mortality rate is 70% .
The risk of death from re- bleed is more
than twice that from the initial bleed .
Any patient with deteriorating symptoms
require a CT scan to exclude re-bleeding

Complications
Hydrocephalus
Obstructive
Blood enters the ventricles & can block the flow of
CSF e.g. at the aqueduct or outlet of the 4th ventricle

Communicating
Due to blood blocking reabsorption of CSF through
the arachnoid granules

May need an extraventricular drain to treat

Keep head of bed at 300 (promote CSF flow &
venous return)

Complications
Vasospasm
Blood vessel goes into spasm causing
ischaemia - stroke
To prevent keep them filled with at least 3L
fluid day & nimodipine
Suspected with deteriorating GCS/new
neurological deficit
Treatment Urgent CT brain to rule out a bleed
as a cause of the deterioration then urgent
angiogram to diagnose & treat vasospasm

Complications

Hyponatraemia
Results from excessive renal
secretion of sodium rather
than a dilutional effect of
SIADH

Complications
Epilepsy
Epilepsy may occur at any stage
after SAH , especially if a hematoma
has caused cortical damage
It may be generalised or partial

Management
Stabilization :
ABC
Intubation if needed and incase of
intracranial hypertension osmotic
diuretics

Management
Prevention of rebleeding
Bed rest
Analgesia
Stool softeners
Aneurysm repair

Management
Prevention of vasospasm
- CCB nimodipine
- Avoidance of anti-hypertensive
therapy for reactive hypertension
- High fluid intake ( haemodilution)
- Plasma volume expansion
( hypervolaemia )

Management
Hyponatremia :
Avoid fluid restriction , hypertonic
sodium chloride
Seizures :
Prophylactic anticonvulsants
( phenytoin)

Operative technique for

aneurysmal repair
- Surgical (clipping of the aneurysmal
neck , wrapping or trapping )
- Endovascular (coil embolisation ,
balloon occlusion )

Clipping of the aneurysm

Wrapping

Trapping
Should be combined
with cerebral
revascularization

Coil embolisation

Coil Embolisation

Complications of clipping
Hemorrhagic complications
Ischemic complication
Damage to parent artery or
perforating artery
Meningitis
Cellulitis and wound infection

Complications of endovascular
therapy
- Aneurysm rupture
- Thromboembolism
- Balloon rupture of deflation

THE END