SAH, Subarachnoid Hemorrhage, Brain Hemorrhage, Stroke

1. ANEURYSMAL
SUBARACHNOID
HEMORRHAGE
Dhaval Shukla
Associate Professor
Dept of Neurosurgery,NIMHANS

2. SAH Etiology- Non Traumatic
• Aneurysmal Rupture : 80-85%
• Non aneurysmal perimesencephalic
haemorrhage : 10%
• Arteriovenous Malformation/ Fistula
• Intracranial vessel dissection
• Venous Sinus thrombosis
• Vasculitis
• Coagulopathy
• Drug abuse/ Cocaine use
• Hypertensive crisis

3. Aneurysm
• Focal outpouching from the arterialwall

4. Epidemiology
• Prevalence of aneurysm 1-6%
• Multiple aneurysm in 20 – 30%
• Only about 20% of them rupture during a
lifetime
– 10/1 lakh population / year (average)
– India – 3-4 (hospital based studies)
– High in Finland and Japan (15-30)
– Low in France, China

5. Risk factors for aneurysm
formation
• Incidence increases with age
– Peak at 50-60 years
– Very rare in children
• Female gender (1.2 – 1.6 times more common)
• Hypertension
• Smoking
• Genetic factors
– Connective tissue disorders (Marfan, Ehler Danlos Syndrome)
– Polycystic Kidney Disease
– Familial occurrence (7 to 20%)

6. Natural History
• 10-12% die before receiving medical
attention
• 40-50 % of hospitalized pts.die within 1
month
• Only 1/3rd of survivors have “good results”.

8. Clinical features
• Sudden severe headache (Thunderclap)
– 1 in 8 to 10 pts with sudden severe headache have SAH
• Nausea, vomiting
• Meningismus
• Altered consciousness / coma
• Focal neurological deficit
• Seizures (10-25%)
• Prodromal symptoms – sentinel bleeds (50%)
• Ocular haemorrhages

9. Pitfalls in clinical diagnosis

10. HUNT AND HESS SCALE.
I - Asymptomatic or with mild headache
II-Moderate or severe headache, nuchal rigidity
III-Confusion, drowsiness, or mild focal deficit
(discounting third nerve palsy)
IV-Stupor or hemiparesis, early decerebrate
rigidity
V-Deep coma, extensor posturing

11. WFNS Grading
Grade GCS Clinical examination
1 15 No motor deficit
2 13-14 No motor deficit
3 13-14 Motor deficit
4 7-12 With or without motor deficit
5 3-6 With or without motor deficit

13. Diagnostic studies
SAH
– CT scan
– Lumbar Puncture
Intracranial aneurysm
– DSA
– CTA
– MRA

14. CT scan
• CT scan head-positive in up to
- 95-100% in 12-24 hours
- 80% in 3 days
- 70% in 5 days
- 50% at1 week
- 30% at 2 weeks
MRI is not sensitive in acute bleed

16. Fisher’s Grade
2
4

17. Modified Fisher’s Grade

18. CT
• Intraventricular Hemorrhage (IVH)
• Hydrocephalus
• Intracerebral hematoma (ICH)
• Brain edema
• Infarction caused by vasospasm

19. Hydrocephalus IVH and ICH

20. Pitfalls in CT diagnosis

21. Lumbar puncture (LP)
• Positive in
o 100% in 12 hrs to 2 weeks
o >70% after 3 weeks
o 40% after 4 weeks

22. Supernatant xanthochromia

23. Pitfalls in LP diagnosis

24. Importance of correct diagnosis !
• A disease of high morbidity and mortality
• Good grade patients are usually
misdiagnosed
• Misdiagnosis ranges 25-50%

26. DSA
• Digital Subtraction Angiography (DSA)
“gold standard”
• Mortality -<0.1%
• Total neurological morbidity - 1%
• Permanent neurological morbidity -0.5%.

27. DSA

28. DSA

29. 3D Rotational angiogram

30. CT Angiogram (CTA)
Demonstrate aneurysms as small as 2 to 3
mm
• Useful for surgical planning
• A screening tool in populations at high risk
• Sensitivity 95 – 97%

31. CT Angiogram

32. Magnetic Resonance
Angiography-
 Takes ½ to 1 hour
 Detects aneurysms >3 to
5 mm
 MRI detects thrombosed
aneurysms
 Screening modality

33. Angiogram-negative SAH
• 15 to 20%
– 65 % are prepontine or perimesencephalic
• Causes
– Vasospasm
– Hypoperfusion
– Poor angiographic technique
– Thrombosis
• Repeat angiography
– Undetected aneurysms found in an additional
2–5% of cases at 2–4 weeks

34. Perimesencephalic bleed
• Venous hemorrhage
• Younger
• Non-hypertensive
• Better grade
• More in males
• Prognosis good
• Re-bleeding is rare
• Delayed ischemic
deficit very few

35. Initial Management
• Absolute bed rest with 30degrees head elevation
• Analgesia- short-acting and reversible agent
– Pain is associated with a transient elevation in blood
pressure and increased risk of rebleeding
• Sedation with a short-acting benzodiazepine such
as midazolam
– Use with caution to avoid distorting subsequent
neurologic evaluation

36. Initial Management
• Hourly neurochecks
• Strict input and output monitoring
• Monitoring BP, oxygen saturation
• Comatose patients
– Intubation and ventilation
• Seizure prophylaxis- Phenytoin
• Stool softeners
• Nimodipine (60mg q4h for 21 days)

37. INVESTIGATIONS
• Hemoglobin, serum electrolytes, glucose,
and arterial gases
• ECG
• Renal and liver function tests
• Chest radiography

38. Specific problems in aneurysmal
SAH
• Rebleeding
• Vasospasm
• Hydrocephalus
• Hyponatremia
• Seizures
• Pulmonary
complications
• Cardiac
complications

39. Rebleed
• Most disastrous and disabling
• Mortality rates-70 to 90 %
• Prevention of rebleed is early intervention

40. Rebleed
• First 24 hrs- 4-6 %
• 1-2 % per day for 2 weeks
( cumulative 20%)
• 30% rebleed by 30 days
• 50% rebleed by 6 months
• There after 3% per year

41. Vasospasm
• Delayed ischemic
neurlogic deficit-
• Onset on the 3rd day
• Peak 6_8 days
• Resolves by 3
weeks

42. Vasospasm
• Clinical Features
- delayed deterioration
- focal neurlogic deficits
- confusion, irritability
- fever
- raised ESR, total WBC count

43. Clinical vasospasm
Lab. Investigations
Hyponatremia
Hypoglycemia
Anemia
Vasospasm management
Euvolemia
Induction of
hypertension
DSA and intra-arterial nimodipine OR
angioplasty
CT scan
Infarct
Hydrocephalus
Hematoma
Normal

44. Hydrocephalus
• Acute hydrocephalus occurs in 15% to 87%
– With IVH - 35 to 65 %
– managed by external ventricular drainage (EVD)
• Chronic shunt-dependent hydrocephalus occurs in
8.9% to 48%
– Chronic hydrocepalus in 50% of pts with Ac. HCP
– Treated with ventricular shunt placement

46. Seizures
• Early 6% to 18%
• Delayed seizures 3% to 7%
• Risk factors
– MCA aneurysm
– Thickness of SAH
– ICH
– Rebleeding
– Infarction
– Poor neurological grade
– History of hypertension
• Prophylactic anticonvulsants in the immediate
posthemorrhagic period
• Routine long-term use of anticonvulsants is not
recommended

47. Medical Complications
of SAH

48. Cardiac Complications
• Hypertension treated requiring
IV medication (27%)
• Hypotension requiring pressors
(18%)
• Life-threatening arrhythmia
(8%)
• Myocardial ischemia (6%)
• Successful resuscitation from
cardiac arrest (4%)
• Troponin I elevation (20%-
68%)
– Regional wall motion
abnormalities (26%)
ECG Changes
• ST segment alterations (15%–
67%)
• T-wave changes (12%–92%)
• Prominent U waves (4%–52%)
• QT prolongation (11%–66%)
• Conduction abnormalities
(7.5%)
• Sinus bradycardia (16%)
• Sinus tachycardia (8.5%)

49. Neurogenic stunned myocardium
• Most severe form of cardiac injury
• Transient lactic acidosis
• Cardiogenic shock
• Pulmonary edema
• Widespread T-wave inversions
• Prolonged QT interval
• Reversible left ventricular wall motion
abnormalities

50. Hyponatremia
• 10% to 30%
• Associated with onset of vasospasm
• Cerebral salt wasting
• Risk factors
– Poor clinical grade
– ACOMA aneurysm
– Hydrocephalus,
• Treatment
– Aggressive volume resuscitation
– 3% saline
– Fludrocortisones

51. Pulmonary complications
• Chest Infection
• Neurogenic
pulmonary edema

52. Definitive treatment
• Microsurgical Clipping OR Endovascular
coiling should be performed as early as feasible
in the majority of patients to reduce the rate of
rebleeding
• Complete obliteration of the aneurysm should be
achieved whenever possible
• Determination of aneurysm treatment, as judged
by both neurosurgeons and endovascular
specialists, should be a multidisciplinary decision
based on characteristics of the patient and the
aneurysm

53. Coiling

54. DACA Aneurysm Coiling

56. Coiling or Clipping
• For patients with ruptured aneurysms
judged to be technically amenable to both
endovascular coiling and neurosurgical
clipping, endovascular coiling should be
considered

57. Clipping preferred
• Patients presenting with large ICH and MCA
aneurysm
• Aneurysm characteristics
– Wide neck
– Blebs
– Geometrically complex with incorporation of branch
artery
– Partially thrombosed
– Giant
• Inability to navigate delivery system
• Patients preference

58. Coiling preferred
• In elderly
• In poor-grade
• Aneurysms of basilar artery

59. Conclusion
• SAH is a NEUROSURGICAL
EMERGENCY
• High index of suspicion is required
• Immediate investigation with a CT scan +/-
LP should be done.
• Securing aneurysm early results in better
outcome

60. Outcome
• Age
• WFNS grade
• Fisher grade
• Size of aneurysm
• Severity of vasospasm