1. Intracranial aneurysms have an incidence of 9 per 100,000 people, with a mortality rate of 60% within 6 months if left untreated. 2. Clinical grading scales like Hunt-Hess, WFNS, and PAASH are used to assess patients presenting with subarachnoid hemorrhage, with PAASH showing slightly better correlation with outcome. 3. Risk factors for poor outcomes from aneurysmal subarachnoid hemorrhage include older age, hypertension, aneurysm size and location, rebleeding, delayed cerebral ischemia, and hydrocephalus.

1. Dr.Abdulgafoor.M.T ;MD
ICU ,ALKHOR HOSPITAL

3. Incidence:9 per 100000(Japan &Finland 15-17)
Mortality:60% within 6 months with
conservative treatment
One third die from rebleeding within 6 months
1.6 times higher in females
Median age of onset 50-60 years
90%of aneurysms less than 10mm and 90% in
ACA circulation
EPIDEMIOLOGY

4. Statement on Definition
 Ruptured intracranial aneurysm’ (RIA)
 Unruptured intracranial aneurysm’ (UIA);
asymptomatic’ or ‘symptomatic’
 A symptomatic UIA usually causes brain nerve
palsy or rarely can cause arterial embolism
 Asymptomatic UIAs are usually found
incidentally
DEFINITIONS BY ESO (EUROPEAN STROKE
ORGANIZATION)

5. Hunt& Hess grading
1.Asymptomatic, mild headache, slight nuchal
rigidity
2.Moderate to severe headache, nuchal
rigidity, no neurologic deficit other than cranial
nerve palsy
3.Drowsiness / confusion, mild focal
neurologic deficit
4.Stupor, moderate-severe hemiparesis
5.Coma, decerebrate posturing
CLINICAL APPEARANCE &GRADING

6. gra
de
GCS Focal neurological deficit
1 15 Absent
2 13–14 Absent
3 13–14 Present
4 7–12 Present or absent
5 <7 Present or absent
WFNS(WORLD FEDERATION OF NEURO
SURGEONS) GRADING

7. Grade(1) GCS 15
Grade(2) GCS 11 to 14;
Grade(3) GCS 8 to10
Grade (4) GCS 4 to 7;
Grade (5) GCS 3.
PAASH(PROGNOSIS ON ADMISSION OF
ANEURYSMAL SUBARACHNOID
HEMORRHAGE) GRADING
Better correlated with outcome than
WFNS

8. FISCHER GRADING
Grade Appearance of hemorrhage
1 None evident
2 Less than 1 mm thick
3 More than 1 mm thick
4
Diffuse or none with intraventricular hemorrhage
or parenchymal extension

9. Modified by Claassen and
coworkers, reflecting the
additive risk from SAH size
and
accompanying Intraventricular
hemorrhage
0 – none
1 - minimal SAH w/o IVH
2 - minimal SAH with IVH
3 - thick SAH w/o IVH
4 - thick SAH with IVH

10. Recommendation
• It is recommended that the initial
assessment of SAH patients,and therefore
the grading of the clinical condition, is
done by means of a scale based on the
GCS
• The PAASH scale performs slightly
better than the WFNS scale, which has
been used more often (Grade3 Level C)
RECOMMENDATION-GRADING

12. Patient factors:Age,Hypertension,High systolic
BP,Alcohol consumption,smoking (for delayed
cerebral ischemia)
Aneurysm factors:Size and site of Aneurysm
Disease associated:Rebleeding,Delayed
cerebral ischemia,Hydrocephalus
Treatment associated:Aneurysm clipping or
coiling
Complications due to prolonged bed rest.
PREDICTORS OF OUTCOME

13. STATEMENT-RISK FACTORS

14. 10% in first degree
relatives
5-8% in first or
second degree
Family history of
Aneurysm in 10%
Polycystic kidney
disease is
associated
RECOMMENDATION-SCREENING

15. CT is useful in the early period .Afterward
redistribution and resorption of blood
occurs.After 5 days of bleed CT can detect only
85% and after 2 weeks 30%
MRI with flair technology comparable to CT in
the early period and superior in the late stage
Water clear CSF during LP rules out SAH within
2-3 weeks
Gold standard :Cerebral
panangiography.(sensitivity 0.77-0.97
&Specificity0.87-1)
DIAGNOSIS

16. RECOMMENDATION-DIAGNOSIS

17. – Intensive continuous observation at
least until occlusion of the aneurysm
– Continuous ECG monitoring
Hourly
 GCS,
 focal deficits,
 blood pressure and
 temperature at least every hour
MONITORING

18. Statement on Physical Management
 Avoid situations that increase
intracranial pressure,
The patient should be kept in bed
Antiemetic drugs, laxatives and
analgesics should be considered before
occlusion of the aneurysm (GCP)
STATEMENT-TREATMENT

19.  Recommendation for Blood Glucose Management
Hyperglycemia over 10 mmol/l should be treated
(GCP)
 Blood pressure Management
Stop antihypertensive medication that the patient
was using
Do not treat hypertension unless it is extreme;
BP limits to be set on an individual basis,depending
on age , pre-SAH BP and cardiac history;
systolic blood pressure should be kept below 180
mm Hg, only until coiling or clipping of ruptured
aneurysm,
RECOMMENDATION-TREATMENT

20. RECOMMENDATION-TREATMENT

21. RECOMMENDATION-TREATMENT

22. RECOMMENDATION-TREATMENT

23. RECOMMENDATION-TREATMENT

24. RECOMMENDATION-TREATMENT
 Sizure at onset 7%
 10% Develop sizure in first few weeks
 Convulsive status epilepticus in 0.2%
 Nonconvulsive status epilepticus in comatose patients 8%
 Continuous EEG –no improvement in outcome
 In one RCT outcome worst in 65% who received
prophylactic antiepileptics Vs 35% in those didn’t receive .

25. RECOMMENDATION-TREATMENT

26. First few hours 15% rebleeds
24 hrs to 4 weeks:35-40% rebleeds
After 4 weeks: 3% per year
Case fatality rate day 1:25-30%
1 week :40-45%
First Month:55-60%
First Year:65%
Five Year:65-70%
12%Die before reaching hospital
OUTCOME

27. Included only aneurysms which can be clipped
or coiled.
90%were good grades
MCA aneurysms underrepresented
Absolute risk reduction of death and disability
after 1 year 6.9%(23.7% Vs 30.6%)
Reduction in relative 5 year mortality in favour
of coiling
Retreatment more in coiling(17.4% Vs 3.8%)
For young patients below 40 years clipping
better
ISAT STUDY

28. RECOMMENDATIONS-INTERVENTION

30. RECOMMENDATIONS-TREATMENT

31. HYDROCEPHALUS

32. RECOMMENDATION

33. RECOMMENDATION-TREATMENT

34. RECOMMENDATION-TREATMENT
Triple H therapy: can cause increased cerebral
oedema, haemorrhagic transformation in areas of
infarction , reversible leucencephalopathy ,
myocardial infarction and congestive heart failure.

35. SAH WITHOUT ANEURYSM

36. Asymptomatic incidental aneurysm
Symptomatic aneurysm
Aneurysms in SAH patients(multiple
aneurysm)
UNRUPTURED ANEURYSM

37. RECOMMENDATION-UNRUPTURED
INTRACRANIAL ANEURYSMS