3. • Many more conditions
Trauma first or pathology first
Seizures Trauma
Loss of consciousness Trauma
Intracranial hemorrhage Trauma
Focal weakness Trauma
4. • It can be spontaneous
• It can be traumatic
• Spontaneous SAH can lead to trauma
(aneurysmal rupture while driving)
• Rupture of traumatic aneurysms can lead to
SAH
Puzzle of spontaneous versus
traumatic SAH
5. • What is subarachnoid space?
• What is SAH?
• What are the causes of SAH?
• What are the clinical features?
• How to make a diagnosis?
• How to plan the management?
First thing first
"The eye cannot see what the mind does not know”
7. • Subarachnoid Hemorrhage (SAH) is a
collection of blood into the subarachnoid
space
• Common source is arteries (ruptured
aneurysm or arteial tears) traversing through
the subarachnoid space
What is SAH?
8. • Traumatic SAH (26-53% of all trauma cases)
• Spontaneous SAH
– Spontaneous rupture of an aneurysm (80-85%)
• Many other diseases
– Cerebral amyloid angiopathy
– Arteriovenous malformation
– Septic aneurysm
– Cocaine associated SAH
– Moya-moya disease
– Sickle cell disease
– Pituitary apoplexy
– Vertebral dissection
– Carotid dissection
Causes of SAH
10. • Elaborate clinical history
• A complete neurological evaluation
– Level of consciousness
– Pupillary examination
– Reflexes
– Motor response
– Clinical history
– Examination
• Look for signs of injuries including C-spine
• Imaging appearance
• A high index of suspicion
Algorithm to approach
11. Investigations: Non-contrast CT scan
• Initial investigation of choice
– Presence of SAH
– Distribution of blood
– Extent of hemorrhage
– Any associated lesions
12. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 33934
Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 4852
13. • Angiography
– CTA
– DSA
– MRA
• Lumbar puncture (Please rule out any
intracranial mass lesions)
Further investigations
15. • Even though etiological classification
categorizes traumatic and non-traumatic or
spontaneous (SAH) separately, in many
aspects the clinical presentation and
management significantly overlaps
• However, differentiation between tSAH and
sSAH is important as the definitive treatment
is not same
Conclusions
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Emergency Medicine Clinics of North America. Elsevier; 2017. p. 803–24.
• Perry JJ, Alyahya B, Sivilotti MLA, Bullard MJ, Émond M, Sutherland J, et al. Differentiation between traumatic tap
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treatment and future directions. Expert Rev Neurother. 2015 Apr 3;15(4):367–80.
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questions. Diagn Interv Imaging. 2015 Jul 1;96(7–8):657–66.
• Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage. Lancet (London, England). 2017 Feb
11;389(10069):655–66.
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• Wong B, Ong BB, Milne N. The source of haemorrhage in traumatic basal subarachnoid haemorrhage. J Forensic
Leg Med. 2015 Jan;29:18–23.
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References