Management of Subarachnoid Haemorrhage

Question 1

Explain the formation of aneurysms

Answer 1

• Occurs when there is excessive haemodynamic stress at branches of arteries, causes weakness in vessel wall, stretching and eventual aneurysm.
• Excessive inflammation and immunological reactions may be indicated

Question 2

What are the causes of subarachnoid haemorrhage?

Answer 2

• Most common are aneurysms but some are related to atriovenous malformation or tumours

Question 3

What are the predisposing factors for aneurysmal subarachnoid haemorrhages?

Answer 3

• Smoking,
• Female sex,
• Hypertension,
• Positive family history
• ADPKD,
• Elhers Danlos syndrome,
• Coarctation of the aorta

Question 4

Explain the presentation of subarachnoid haemorrhages

Answer 4

• Sudden onset of a severe headache.
• May also present with a LOC, seziures, visual/speech/limb disturbance .
• Sentinel headache which can occur weeks before presentation

Question 5

What can be seen on a clinical examination of a subarachnoid haemorrhage?

Answer 5

• Photophobia,
• Meningism,
• Subhyaloid haemorrhages (found between vitreous and retina),
• Vitreous haemorrhages,
• Speech and limb disturbances,
• Cardiovascular problems

Question 6

What is the grading system for subarachnoid haemorrhages?

Answer 6

WFNS grades.
Grade 1 = GCS 15.
Grade 2 = GCS 13-14 without deficit.
Grade 3 = GCS 13-14 with deficit.
Grade 4 = GCS 7-12
Grade 5 = GCS 3-6

Question 7

What are the investigations for subarachnoid haemorrhages?

Answer 7

• CT STAT. It will confirm the diagnosis, give clue to aetiology, show complications
• LP which will show xanthochromia (bilirubin in CSF). Should be preformed 12h after presentation. Only done if CT is negative.
• CT angiogram (identify cause, uses contrast so check eGFR). Can also use MR angiogram
• Others: UEs, ECG, troponin and ECHO(tako tsubo cardiomyopathy)

Question 8

What is the resuscitation management for subarachnoid haemorrhages?

Answer 8

• Bed rests with antiembolic stockings
• 2.5-3.0L of fluids
• Nimodipine (calcium channel antagonist, prevent ischaemia)
• Analgesia
• Doppler studies

Question 9

What is the management of subarachnoid haemorrhages

Answer 9

• Endovascular via coils (goes through the groin, can be used with a stent)
• Surgical clipping
• Conservative

Question 10

What are the complications of subarachnoid haemorrhages

Answer 10

• Rehaemorrhage (more common with large aneurysm)
• Delayed ischaemia,
• Hydrocephalus (blood causes immune response to granulation tissue and increased CSF)
• Hyponatraemia,
• CV problems eg, LV failure (tako tsubo cardiomyopathy)
• DVT, PR, UTI or lower respiratory tract infection

Question 11

What is the management of hydrocephalus?

Answer 11

• LP
• External ventricular drainage,
• Shunt

Question 12

What is the management of delated ischaemia after subarachnoid haemorrhages?

Answer 12

• Fluid management,
• Nimodipine,
• Ionotropes,
• Angioplasty (balloon stenting)

Question 13

Why is the management of hyponatraemia following a subarachnoid haemorrhage?

Answer 13

• Establish volume status and give hypertonic saline and fludrocortisone (mineralocorticoid)

Question 14

What are the cardiopulmonary complications following a subarachnoid haemorrhage?

Answer 14

• Sympathetic stimulation and catecholamine release can lead to myocardial injury (stunned myocardium)
• lower RTI
• Tako tsubo cardiomyopathy