Subarachnoid Hemorrhage

Hania EL JARKASS, MD
Neurology
MGH
Stroke ; 20 % hemorrhagic:
• 10% intracerebral
• 10% SAH
• Most SAHs are caused by ruptured saccular
aneurysms.
9/27/2021© 2009, American Heart
Association. All rights reserved.
 SAH
• What is it?
– Bleeding into the subarachnoid space where blood vessels
lie & CSF flows

• Where does the blood come from?

– An aneursym on a blood vessel in the subarachnoid space
has ruptured (~70%)
– Unknown (~15%)
– AVM (~10%)
– Rare causes (e.g. tumour) (~5%)

• Where does the blood go?

– Anywhere where CSF goes, may get hydrocephalus if into
ventricle & causes obstruction of CSF circulation
9/27/2021© 2009, American Heart
Association. All rights reserved.
 SAH – The Problem
• They occur in young people
– 80% in 40-65 year olds
– 15% in 20-40 year olds

• It can kill quickly

– 25% die within 24 hours
– 50% will be dead at 6 months

• It causes significant disability

– Cognitive impairment
– Neurological disability depending on size of bleed &
complications encountered
 SAH
• Incidence = 1/7000 people
• SAH incidence varies greatly between countries, from 2 cases/ 100,000 in China to
22.5/100,000 in Finland

• Higher chance if:

– Female
– 3rd trimester of pregnancy
– Middle-aged
– HTN,
– smoking
– OH
– Abuse of stimulant drugs
– Connective tissue disorder
– Family history
– PCKD 15% who have PCKD have aneurysm
– Aneurysms with a diameter of 5 mm or less have a 2% risk of rupture, whereas
40% of those 6-10 mm have already ruptured upon diagnosis
– Posterior circulation aneurysm
 Clinical Picture
• 1ry symptom is thunderclap headache (97 percent of cases)
, lateralized in 30 percent of patients, more toward to the
side of the aneurysm

• The onset may or may not be associated with a brief loss of

consciousness, nausea or vomiting, and meningismus

• Meningismus develop several hours after the bleed due to

breakdown of blood products within the CSF, which lead to
an aseptic meningitis

• 30 to 50 % report a history of a sudden and severe

headache (the sentinel headache) that precedes a major
SAH by 6 to 20 days ( warning leak) Several headaches then thunderclap
 Diagnosis
• Head CT scanThe cornerstone of SAH diagnosis
• The sensitivity is highest in the first 6 to 12 hours
after SAH (nearly 100 percent) and then
progressively declines over time to about 58
percent at day 5

• Brain MRI FLAIR have a high sensitivity in patients

with a subacute presentation of SAH (>4 days from
the bleed)
CT Scan non-contrast showing blood in basal
cisterns (SAH) – so called “Star-Sign”

CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery

9/27/2021© 2009, American Heart

Association. All rights reserved.
Radiological grading of SAH
• Lumbar puncture :is mandatory if there is a strong
suspicion of SAH despite a normal head CT
• The classic findings of SAH are an elevated opening
pressure and an elevated RBC count. The differential
of RBC between tubes one and four, and immediate
centrifugation of the CSF can help differentiate
bleeding in SAH from that due to a traumatic spinal
tap
• Xanthochromia (pink or yellow tint) represents
hemoglobin degradation products. xanthochromic
supernatant in CSF is highly suggestive of SAH (2h-
2weeks)
• CT and MR angiography : noninvasive tests /can identify aneurysms 3
to 5 mm or larger/Rapid and obtained immediately after the diagnosis

• Patients with negative angiography Repeat angiography : No

angiographic cause is evident in 14 to 22 %. repeat the angiogram in 4
to 14 (find 24%)

• Perimesencephalic hemorrhage (10%) initially negative angiogram

plus blood in the cisterns around the midbrain/Most do not have an
aneurysm or other defined etiology/ more favorable prognosis
 Angiogram - Giant
ICA Aneurysm

Angio image courtsey: University of Texas Health Science Center at San Antonio - Department of Neurosurgery

9/27/2021© 2009, American Heart

Association. All rights reserved.
Differential Diagnosis
 Complications
Rebleeding :8 to 23 % of patients. risk of rebleeding is highest in
the first 24 hours . independent predictors of rebleeding
include:
– the Hunt-Hess grade on admission
– maximal aneurysm diameter
– a higher initial blood pressure
– a sentinel headache preceding SAH
• Only aneurysm treatment is effective for the prevention of
rebleeding
• MR may reach 70 %
Vasospasm and delayed cerebral ischemia40 to 60 % / 5-7 days after SAH
• Risk factors:
– Younger patients (<55 years)
– severity of bleeding and its proximity to the major intracerebral blood vessels
– Hyperglycemia, hypovolemia

Hydrocephalus : in 15 %
• Factors associated with an increased :
– intraventricular hemorrhage,
– posterior circulation aneurysms
– and a low Glasgow score on presentation
– hyponatremia or a history of hypertension
– Older age
• caused by obstruction of CSF flow by blood products or adhesions (obstructive),
or by a reduction of CSF absorption at the arachnoid granulations (non
obstructive)
Increased ICP : due to :
o hemorrhage volume,
o acute hydrocephalus,
o distal cerebral arteriolar vasodilation around 50
percent

Seizures : Acute seizures occur in 6 to 18 percent /

predictor of poor outcome

Hyponatremia : probably mediated by hypothalamic injury.

May result from either the syndrome of inappropriate
ADH secretion or, much less often, volume depletion
induced by cerebral salt wasting
 Management
• Admission to an intensive care
• endotracheal intubation if: include a GCS ≤8 ,
elevated ICP, poor oxygenation ,hemodynamic
instability and requirement for heavy sedation
• DVT prophylaxis with pneumatic compression
stockings prior to aneurysm treatment
• Intravenous fluid administration should target
euvolemia and normal electrolyte balance
• Patients are given stool softeners, kept at
bedrest, and given analgesia
• Prophylactic therapy for gastrointestinal ulcers
PPI for stress ulcers prevention
• Anticoagulants and antiplatelet agents should
be discontinued
• SBP <160mm Hg is reasonable
• the use of AEDs for seizure prophylaxis after
SAH should probably be minimized
But once seizure occurs → treat

• PREVENTION OF VASOSPASM AND DELAYED

CEREBRAL ISCHEMIA: nimodipine 60 mg q 4h
PO 4h after SAH, and euvolemia should
maintained

• ANEURYSM TREATMENT
Clipping

9/27/2021© 2009, American Heart

Association. All rights reserved.
 Left image arrow -Angio with Large aneurysm
Right image arrow – Angio showing aneurysm post clipping

Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery
9/27/2021© 2009, American Heart
Association. All rights reserved.
Coiling

9/27/2021© 2009, American Heart

Association. All rights reserved.
 Coil system embolization: immediate result

Angio showing large ICA aneurysm

Same aneurysm - Post GDC Coiling

Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery
9/27/2021© 2009, American Heart
Association. All rights reserved.
Arterial bypass
MANAGEMENT OF COMPLICATIONS
• Symptomatic vasospasm "triple-H" therapy,
included modest hemodilution, induced
hypertension and hypervolemia ;to raise the
mean arterial pressure and increase cerebral
perfusion

• Hydrocephalus :Ventricular drain placement/

1/3 to 1/5 of patients with acute
hydrocephalus develop chronic shunt-
dependent hydrocephalus
• Hyponatremia :
o Patients with SIADH are euvolemic. fluid restriction is not
desirable in patients with. Thus, hyponatremia is treated with
isotonic saline, or, if necessary, hypertonic saline
o Cerebral is characterized by volume depletion, which leads to
the release of ADH. It is usually treated with infusions of
isotonic saline

• Seizures: antiepileptics
 Prognosis
• Mortality rate may reach 51 percent

• Long term complications of SAH include neurocognitive

dysfunction, epilepsy, and other focal neurologic deficits

• Recurrence of SAH which can occur despite successful

endovascular or surgical treatment of the ruptured
aneurysm

• First-degree relatives of patients with SAH have a two- to

five- fold increased risk of SAH compared with the general
population / may be reasonable to screen some family
members
THANK YOU