Subarachnoid Haemorrhage

Question 1

How does a subarachnoid haemorrhage typically present?

1. symptoms? [6]
2. signs? [3]

Answer 1

• Symptoms:
  
  1. Sudden onset of excruciating headache, typically occipital (“thunderclap” headache)
  2. Vomiting
  3. Collapse
  4. Seizures
  5. Coma/drowsiness
  6. Preceding “sentinel” headache (perhaps due to a small warning leak from the offending aneurysm)
• Signs:
  
  1. Neck stiffness
  2. Retinal, subhyaloid and vitreous bleeds = Terson’s syndrome
  3. Focal neurology at initial presentation may suggest site of aneurysm (e.g. pupil changes → 3rd nerve palsy with posterior communicating artery aneurysm) or intracerebral haematoma

Question 2

What is the most common cause of a subarachnoid haemorrhage and what are the common sites of this abnormality? [4]

Answer 2

1. Mostly caused by berry aneurysm rupture
2. Common sites:
   
   • junction of posterior communicating with the internal carotid artery
   • junction of anterior communicating with the anterior cerebral artery
   • bifurcation of the middle cerebral artery

Question 3

What are the differential diagnoses for subarachnoid haemorrhage? [6]

Answer 3

1. Meningitis
2. Migraine
3. Intracerebral bleed
4. Cortical vein thrombosis
5. Dissection of a carotid or vertebral artery
6. Benign thunderclap headache (triggered by Valsalva manoeuvre, e.g. cough, coitus)

Question 4

What investigations would you carry out on a patient with suspected subarachnoid haemorrhage? [8]

Answer 4

1. Urgent CT scan
2. Consider lumbar puncture
3. CT angiography/MRA
4. Digital subtraction angiography (DSA)
5. Bloods:
   
   • Hyponatraemia
6. ECG
7. Elevated troponin
8. Echocardiogram

Question 5

Describe how the WFNS Grading is used to grade subarachnoid haemorrhages [5]

Answer 5

1. Grade I → GCS 15
2. Grade II → GCS 13-14 without deficit
3. Grade III → GCS 13-14 with deficit
4. Grade IV → GCS 7-12
5. Grade V → GCS 3-6

Question 6

How is a patient with a subarachnoid haemorrhage managed? [9]

Answer 6

1. Resuscitation:
   
   • Bed rest
   • Fluids (2.5-3L normal saline)
   • Anti-embolic stockings
   • IV nimodipine
   • Analgesia
2. Surgical clipping
3. Endovascular treatment
4. Conservative

Question 7

What are the potential complications of a subarachnoid haemorrhage? [8]

Answer 7

1. Re-haemorrhage
2. Delayed ischaemia
3. Hydrocephalus
4. Hyponatraemia
5. ECG changes, left ventricular failure (LVF)
6. Lower respiratory tract infection (LRTI),
7. Pulmonary embolism (PE),
8. UTI

Question 8

How could you potentially get hydrocephalus as a complication of a subarachnoid haemorrhage and how would you manage this? [2]

Answer 8

1. due to blockage of arachnoid granulations
2. requires a ventricular or lumbar drain