A. 20 - Diagnosis, treatment and prognosis of subarachnoid hemorrhage (SAH)

Question 1

Etiology of subarachnoid hemorrhage (SAH)?

Answer 1

● Aneurysms (75%)
● perimesencephalic hemorrhage (10%)
● A-V malformations (5%)
● 20% of investigations fail to reveal the source

Question 2

Signs and symptoms of subarachnoid hemorrhage (SAH)?

Answer 2

● Severe headache w/ instantaneous onset
● Loss of consciousness, coma
● Epileptic seizure
● Nausea, vomiting
● Neck stiffness present in most pts
● Focal signs (e.g. limb weakness, dysphasia)
● Reactive hypertension
● Pyrexia

Question 3

diagnosis of subarachnoid hemorrhage (SAH)?

Answer 3

● Urgent CT:
detects 95% of SAH within 24h

● Lumbar puncture:
- if CT is neg. but history is very suggestive of SAH
- needs to be done >12h after headache onset to allow breakdown of RBCs
( pos. sample → xanthrochromic -yellow due to bilirubin- )

● MRI:
may be used in pts w/ multiple aneurysms

● CT/MR angiography, digital angiography:
more detailed info

Question 4

Management of subarachnoid hemorrhage (SAH)?

Answer 4

immediately refer to neurosurgery!

● Re-examine CNS often (BP, pupils, GCS)
● Maintain cerebral perfusion by keeping well hydrated (aim for SBP<160 mmHg)
● Nimodipine to prevent vasospasms
● Surgery:
- within 48h, if not a delayed intervention is recommended (after 14 days)
○ Endovascular coiling vs. surgical clipping , depending on accessibility and size of
aneurysm (coiling is preferred)
○ Balloon remodelling and flow diversion are newer techniques used for anatomically
challenging aneurysms

Question 5

prognosis subarachnoid hemorrhage (SAH)?

Answer 5

● Mortality in SAH
○ Grade I: no signs → 0%
○ Grade II: neck stiffness and CN palsies → 11%
○ Grade III: drowsiness → 37%
○ Grade IV: drowsy w/ hemiplegia → 71%
○ Grade V: prolonged coma → 100%

● Most mortality occur in 1st month (90% of survivors of 1st month survive >1 year)