Subarachnoid Haemorrhage

Question 1

List 3 causes of non-aneurysmal subarachnoid haemorrhage.

How common are they?

Answer 1

No underlying cause
Arteriovenous malformations (AVM)
Malignancy

10-15% of spontaneous SAH

Question 2

Briefly describe the pathophysiology of aneurysmal subarachnoid haemorrhage. (2)

Answer 2

1. Haemodynamic stress on the vessel walls causes inflammation and weakening
   a. This causes dilation, forming an aneurysm
2. When the aneurysm gets too big, it can rupture

Question 3

List 7 risk factors for aneurysmal SAH.

Answer 3

Smoking
Female sex
Hypertension
Family history

Rare conditions, e.g.

• Autosomal dominant polycystic kidney disease
• Ehlers Danlos syndrome
• Coarctation of the aorta

Question 4

List 4 signs found on examination of SAH.

Which specific exam do you need to do? List 2 more features found here.

Answer 4

Photophobia
Meningism
Speech/limb disturbance
Pulmonary oedema

FUNDOSCOPY:
Subhyloid haemorrhage
Vitreous haemorrhage (Terson’s syndrome)

Question 5

What is Terson’s syndrome?

Answer 5

Vitreous haemorrhage associated with SAH

Question 6

List 5 clinical features of SAH.

Answer 6

Thunderclap headache
Loss of consciousness
Seizures
Visual/speech/limb disturbance
Sentinel headache (30-40%)

Question 7

List 9 complications of SAH.

Answer 7

Infarction
Delayed ischaemia
Haematoma
Hydrocephalus
Re-haemorrhage
Hyponatraemia
Cardiopulmonary complications
Seizures
Infections (e.g. LRTI, UTI)

Question 8

What does tako-tsubo cardiomyopathy indicate?

Answer 8

Left ventricular failure

Question 9

Give 7 examples of cardiopulmonary complications of SAH.

Answer 9

Elevated troponin
Arrhythmias
Wall motion abnormalities
Sudden death
Tako-tsubo cardiomyopathy
Pulmonary embolism
DVT (needs prophylaxis!)

Question 10

Describe the grading of SAH via the WFNS system.

Answer 10

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 11

List 7 investigations you would do for SAH.

Answer 11

CT scan
Lumbar puncture
CT angiogram
MR angiogram
Digital subtraction angiogram (DSA)
Blood tests
ECG/CXR

Question 12

Describe the grading of SAH on CT scan via the Fisher system.

Answer 12

Grade 1:
No SAH/intraventricular haemorrhage

Grade 2:
Diffuse, thin (<1mm) SAH
No clots

Grade 3:
Localised clots
SAH which is 1+mm
Possible intracerebral/interventricular haemorrhage

Grade 4:
No/thin (<1mm) SAH
Intracerebral/interventricular haemorrhage present

Question 13

What do you look for on a lumbar puncture for SAH?

What is this?

Answer 13

Xanthochromia

Yellowing of CSF due to presence of bilirubin

Question 14

Describe the immediate management of SAH. (5)

What other test would you do?

Answer 14

Bed rest
Fluid replacement
Anti-embolic stockings
Nimodipine 
Analgesia

Doppler studies

Question 15

Describe the methods of fixing aneurysmal SAH.

Answer 15

Surgical clipping

Endovascular investions, e.g.

• Coils
• Stents
• Glue

Conservative treatment