SAH

I recommend to go back to the slides for more pictures and listening to the voice record for
better orientation and understanding and to have a bigger picture in your mind about this
topic

o The worst case that you can face as a neurosurgeon because it can deteriorate and lose
the patient
o Subarachnoid space : space between the arachnoid membrane and the pia mater

o Giant subarachnoid spaces = Cisterns ( Ambient Cistern , quadrigeminal cistern, Sylvian

cistern, suprasellar cistern,…etc. )

• Causes:

1- Trauma ( most common )

2- Spontaneous ( 2nd most common, worse and multi-causes )
Ruptured Berry Aneurysm 75-80%
AVM 4-5% ( 7% associated with Aneurysm )
Vasculitis, tumours, HTN , carotid dissection 3-5%

• Unknown 10-15% (usually Perimesencephalic subarachnoid hemorrhage (PMSAH)

in front of brain stem )

• Major cause of Mortality and Morbidity is Re-bleeding ( high risk 38% )

o Most of Aneurysms occur in the anterior circulation 85-95%

o Multiple Aneurysms 20-30%

• 50% of patients have a warning symptoms 1-3 weeks before SAH ( More than one visit
to the emergency ( 2-3 visits ) and a complaint of headache and neck pain but after
examination the patient is completely normal and GCS is 15 out of 15 ➡ after few
weeks the patient deteriorate, GCS = 3 ( on ventilator ) ➡ we lose the patient because of
sentinel haemorrhage)

• If SAH is too large in volume it could transform to intra-cerebral haemorrhage or

Intraventricular haemorrhage

• Aetiology:

Could be Congenital , genetic , associated with infection ( Mycotic Aneurysm ) ,

Atherosclerosis
But the most important factor is HTN.
 • Risk factors ( Rupture of Aneurysm)
HTN
Diurnal variation in blood pressure
Smoking
Alcohol consumption
Coffee consumption
Oral contraceptives
Drug abuse

• Clinical features
• rupture 95-97%
• Sudden onset of severe headache ( worst headache in the patient life )
• Associated with vomiting ( due to severe pain or increased ICP or meningeal irritation )
• LOC
• Focal cranial nerve deficits ( cranial nerves palsy )
.Back pain, Neck pain
• Nuchal rigidity, Kernig's, Brudzinski's sign
• Sentinel hemorrhage causes warning Headache

• Evaluation: Brain CT ( After History and Physical examination )

1- may implicate which aneurysm is ruptured in case of multiple aneurysms ( Right Sylvian
fissure Right MCA , Left Sylvian fissure Left MCA , Brain stem Basilar Artery )

2- Complications ( ICH , IVH , Hydrocephalus , Re-bleeding , Vasospasm , …etc.)

We cannot depends on CT scan to diagnose haemorrhage acutely ( minimal bleeding or

in the first hour ) so if you have clinical suspension of SAH don’t tell the patient you’re
ok it’s just a headache, instead of that admit the patient and wait .
 • Gold standard test to diagnose SAH is ( Lumbar Puncture ) take 3 samples ( all
samples should have similar values of RBCs in order to say there’s a true SAH )

Next steps ( initial management )

1- admission to ICU
2- if the patient deteriorate ( GCS decreasing ) buy time and put him on ventilator
3- Monitor the vital signs ( to protect the patient from the vasospasm we
prefer to keep the patient a little-bit HTN or highest level of normal ( gentle volume
expansion 140-160 BP ) )
4- make the patient NPO to be ready for any urgent surgery
5- Foley’s catheter ( input and output ) one of the complications of SAH is
electrolytes disturbance ( Hyponatremia ) due to ( cerebral salt wasting syndrome ) and (
SIADH )
6- Blood tests ( CBC, Electrolytes, Hgb , …etc )
• Angiogram: ( GOLD standard test to diagnose the Cause of SAH )

choroid plexus calcification



Hydrocephalus + IVH. Hydrocephalus + ICH

Traumatic ICA Aneurysm.


ACA Aneurysm. Basilar Artery Aneurysm

Hunt & Hess Grading

 WFNS Grading

• Fisher grading system ( for CT image )

• Higher Fisher grade Higher risk of Vasospasm

 • Medication:

Severe headache ( caused by meningeal irritation ) ➡ give ( Dexamethasone ) + Paracetamol

Antiemetic for recurrent vomiting

Stool softeners, H2 blockers ( as prophylactic )

• Ca channel blockers Nimodipine ( as Neuro protector from the effect of Vasospasm not
as anti hypertensive medication )

• Prophylactic anticonvulsant usually phenytoin is controversial

• Vasospasm :

• If Vasospasm happen ➡ Triple H therapy ( 1- HTN, 2- Hydration , 3- Haemodilution)

 • Hyponatremia ( dilutional hyponatremia ) caused by over hydration or SIADH vs CSWS
( release of Brain natriuretic peptide (BNP) )

Radiological vasospasm Clinical vasospasm

constricted vessels without symptoms of ischemia With clinical symptoms. Never ever
on Angiogram may happen in the first day happen before day 3

 • Treatment:

• Avoid surgery in the vasospasm period ( 3rd day - 2 weeks )

explanation: in the vasospasm period the aneurysm size is smaller than the actual
size so after vasospasm effect wears off there will be unsecured part of the
Aneurysm ➡ higher risk

• Early surgery within (72 hours): prevention of re-bleeding , decrease fisher grade
,decrease risk of vasospasm
But the brain is oedematous , swollen , ➡ higher risk of intra-operative injury

• Late surgery after (2 weeks ): we sure that vasospasm ends and the edema resolve but
we put the patient under the risk of re-bleeding
 • Clipping vs Coiling vs surgical
1- Aneurysm configuration ( dome to neck ratio / wide or narrow neck )
2- age ( Coiling have a risk of recanalization )
3- huge intra-cerebral haemorrhage causing shifting of the midline
4- Your ability
• PCOM Aneurysm ( One of the explication of spontaneous 3rd nerve palsy )
• AVM
( in Young patients always rule-out vascular anomalies and do angiogram )
Thanks
Best wishes
Done by ‫ﻣﺠﺎھﺪ اﺳﻌﺪ اﻟﻠّﯿﻤﻮن‬