ddhaha

2. ENLS Version 4.0
Subarachnoid Hemorrhage
Content: Sayona John, MD; William J. Meurer, MD, MS;
Stephanie R. Qualls, RN, BSN, CNRN; and Brian L. Edlow, MD
Slides: George A. Lopez, MD, PhD

3. Presenter:
Your name
Your institution
Conflicts:
No conflicts

4. Editors’ Note: Global Considerations
The intent of the editors, authors, and reviewers of this ENLS topic was not to
address all the variations in international practice for the different diseases. We
have discussed major practice variances (e.g., the availability of diagnostic
testing, or the type of medications used) and encourage learners to use the
ENLS algorithms as a framework on which any relevant local practice
guidelines can be incorporated.

6. ENLS: Subarachnoid Hemorrhage
Learning Objectives:
• Recognize the signs and symptoms
of SAH
• Implement clinical and diagnostic
assessment of suspected SAH
• Recognize initial assessment and
early treatment and resuscitation of
the SAH patient

7. Case
• 39-year-old woman presents with severe headache, uncertain time of onset,
associated with nausea
• PMH: history of migraine headaches
• Meds:
 Reports taking ibuprofen prior to ED, with moderate improvement of
headache
 Taking warfarin for a pelvic DVT - year prior during pregnancy
• Exam: sleepy, yet follows commands, left eye droop and dilated pupil,
moving all extremities
• BP 170/95 mmHg, RR 24/min, HR 98/min
• Breathing pattern is shallow and rapid

9. CLASSIC NOT-SO-CLASSIC
Abrupt onset of severe headache
(HA), i.e. thunderclap
HA is not reported as abrupt (patient
may not remember event well)
NEW, QUALITATIVELY DIFFERENT
HA
HA responds well to non-narcotic
analgesics
May have nausea, vomiting and neck
pain
HA resolves on its own in few hours
May transiently lose consciousness,
present in coma, or have focal
deficits
40% patients with aneurysmal SAH
will have normal neuro exam without
meningismus
Nature of HA onset distinguishes
from other forms of stroke
Do not necessarily appear acutely ill
Clinical Features

10. Clinical Features
Key Exam Features:
• GCS
• Pupil exam
• Fundoscopic exam for
vitreous/retinal hemorrhages
• Neck exam for meningismus
(versus neck pain)
• Hunt and Hess or WFNS score

11. Clinical Severity
Hunt & Hess Clinical Grading Scale
Grade Criteria
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
Grade Criteria
1 GCS 15
2
GCS 13-14, without neurological
deficit
3 GCS 13-14, with neurological deficit
4 GCS 7-12
5 GCS 3-6
World Federation Neurological Scale

12. Case
• 39-year-old woman presents with severe headache, uncertain time of onset,
associated with nausea
• PMH: history of migraine headaches
• Meds:
 Reports taking ibuprofen prior to ED, with moderate improvement of
headache
 Taking warfarin for a pelvic DVT - year prior during pregnancy
• Exam: sleepy, yet follows commands, left eye droop and dilated pupil,
moving all extremities
• BP 170/95 mmHg, RR 24/min, HR 98/min
• Breathing pattern is shallow and rapid

13. Case: 39-year-old woman with HA
What’s the first step?
A. STAT head CT
B. STAT brain MRI
C. Assess ABC’s
D. Start IV nicardipine drip
E. Order FFP and vit K

14. Case: 39-year-old woman with HA
What’s the first step?
A. STAT head CT
B. STAT brain MRI
C. Assess ABCs
D. Start IV nicardipine drip
E. Order FFP and vit K

15. Checklist
☐ Airway, breathing, circulation
☐ Head computed tomography (CT)
☐ Labs: PT/INR, PTT, CBC, chemistries, troponin, toxicology screen
☐ 12-lead ECG
☐ Target SBP goal < 160 mmHg
☐ Consult neurosurgery/NCC team
☐ Address hydrocephalus if present

17. • Non-contrast CT imaging of the brain is the gold standard for
identifying SAH with sensitivity of 95-100% if:
• Classic presentation with thunderclap HA
• CT completed within six hours of HA onset
• The patient is completely
neurologically intact
• The CT is read by an
attending radiologist
• Sensitivity of CT decreases
with time
• False negative CT: time,
anemia (hct <30) low
volume SAH, a technically
poor scan
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3 days 1 week 2 weeks
Sensitivity
Time Since Headache Onset
Sensitivity CT for SAH
Brain Imaging

18. CTA → ACOM aneurysm
Adjunct Brain Imaging
CTA
• Some advocate for a CTA at the time of the CT
scan to look for an intracranial aneurysm.
• Caution regarding renal function and contrast
administration.
• Although CTA is helpful if an aneurysm is seen,
the negative predictive value is less clear.
• One should not use a negative CTA alone to
rule out aneurysmal SAH.

19. MR SWI Sequence
Brain Imaging
• MRI may be useful in patients who
are imaged a few days or week or
longer following the SAH
• Specific sequences can be used to
image subarachnoid blood even
several days later

20. Head CT (-)
Lumbar Puncture
• Must perform LP if CT is negative
and history suggests SAH
• Rationale for LP is to confirm
xanthochromia-staining of CSF
by heme breakdown products
• Presence of xanthochromia is
time dependent - takes >12 hours
to develop

21. Typical LP Findings Atypical or Inconclusive Not suggestive of SAH
↑ RBCs,
No clearing from tube 1→ 4
Clearing of RBCs from tube 1→ 4 CSF clear of RBCs
< 5 WBC,
WBC:RBC ratio 1:700
↑ WBC:RBC ratio suggest another
process, meningitis or encephalitis
Occasionally, rapidly expanding
unruptured aneurysm may
present with HA, recommend
urgent consultation
Xanthochromia present
(However if CSF Protein
>100mg/dL may be false positive)
Xanthochromia absent
(Assuming LP is done more than 12
hours following headache onset).
Xanthochromia absent
Opening pressure elevated (~2/3
patients)
OP normal OP normal
Lumbar Puncture

22. Diagnosis of SAH
Confirmed
Once SAH is confirmed,
the goal is to reduce the
chance of aneurysm re-
rupture and expedite
treatment of the
aneurysm while
preventing or minimizing
medical or neurologic
complications.

23. Management

24. Initial Orders
Once SAH is diagnosed, initial orders should include:
• Bed rest
• Obtain pre-intervention labs: CBC, platelets, PT/PTT,
INR, electrolytes, BUN, Cr, cardiac enzymes
• 12-lead ECG
• Cardiac telemetry
• Nimodipine 60 mg po/ng (watch for hypotension)
• Antiseizure medication until aneurysm is secured
• Consult Neurosurgery/NCC

25. Seizure Prophylaxis & Management
Prophylactic Antiseizure Meds - Controversial
• Pro: seizures following SAH and prior to definitive treatment has
been associated with re-rupture and can raise ICP.
• Con: phenytoin use has been associated with worse cognitive
outcomes in SAH.
• One strategy is to administer a loading dose of phenytoin in the
ED, and continue it until the aneurysm is secured, then stop the
medication unless seizures have occurred.
• Although frequently used by many centers, there is limited data on
use of alternative anticonvulsant agents such as levetiracetam.
Active Treatment of Seizures
• Administer lorazepam for acute seizure management
• Administer loading dose of IV phenytoin
• More recently, many centers use levetiracetam

26. Coagulopathy
Correct underlying coagulopathies
• Goal INR < 1.4
• Goal platelet count > 50,000
• Consider platelet transfusion for those
on anti-platelet medication(s)
• See ENLS Pharmacology manuscript

27. Treat Pain & Anxiety
• It is important to avoid straining, Valsalva and
writhing, as they can potentially contribute to re-
rupture of an aneurysm
• One must also be careful not over-sedate the
patient as one could mask the symptoms of
hydrocephalus
• Use IV medication with short half-life (fentanyl)
• Liberal use of anti-emetics is justified especially
if vomiting occurs
• BP control is enhanced with adequate analgesia
• If anxiety seems to be the major issue, consider
small doses of an anxiolytic such as lorazepam

28. BP Management
• Precise guidelines for BP management in SAH
unfortunately do not exist
• Retrospective data suggest higher rates of re-bleeding with
SBP > 160 mmHg
• Over treatment of BP can potentially lead to brain ischemia
- especially if hydrocephalus or vasospasm is present.
• Pre-morbid BP should be taken into considerations
• Experts recommend to aim for SBP < 160 mmHg, or
MAP < 110 mmHg, keeping above principles in mind
• Use short acting, titratable intravenous medications such
as beta blockers or nicardipine
• Avoid long-term nitroprusside due to concern of raising ICP

29. Initial CT
Case: 39-year-old woman with SAH
Back to our patient:
• Patient’s level of consciousness
abruptly declined
• Blood pressure spiked to 220/115
mmHg

30. Case: 39-year-old woman with SAH
What’s the next step?
A. Assess ABCs, intubate if necessary
B. Give IV dose of antihypertensive drug, add drip
for longer BP control
C. STAT head CT
D. A and C
E. A, B and C

31. Case: 39-year-old woman with SAH
What’s the next step?
A. Assess ABCs, intubate if necessary
B. Give IV dose of antihypertensive drug, add drip
for longer BP control
C. STAT head CT
D. A and C
E. A, B and C

32. CT Following Neurologic Deterioration
Case: 39-year-old woman with SAH
Patient’s level of arousal abruptly
declined:
• Required immediate intubation
• Both pupils transiently dilated
• Head CT demonstrated re-bleeding
associated with acute
hydrocephalus
• Upon return from CT, patient had a
generalized seizure, requiring
treatment with intravenous
lorazepam

33. Re-rupture estimate 12-15% in the
initial 24 hours
Decline in Neurological Status
Causes of decline in neurological status:
• Acute re-rupture of the aneurysm
• Acute hydrocephalus
• Seizure
• Cardiopulmonary complications
• Neurogenic pulmonary edema
• Neurogenic stress cardiomyopathy
• Note cardiovascular collapse may be a sign of
cerebral herniation

34. EVD
Hydrocephalus
• Hydrocephalus is caused by blockage of CSF circulation and
absorption within the ventricular system +/- increased CSF
production
• If a patient is obtunded or comatose, a ventricular drain (EVD) can
be placed. This treats the hydrocephalus and provides monitoring
of ICP
• If a neurosurgeon is not available:
 Transfer immediately to a facility with NS capabilities
 Consider mannitol 1 gm/kg or hypertonic saline in the interim

35. Anti-fibrinolytic Agents
• Preventing re-rupture of the aneurysm is a goal of initial SAH
management
• Antifibrinolytic agents such as ε-aminocaproic acid and
tranexamic acid can reduce aneurysmal re-rupture
• These agents also raise the risk of thrombosis such as DVT, PE,
and ischemic stroke, if they are continued beyond the acute SAH
period
• If there is an unavoidable delay in obliteration of the aneurysm
and the patient is free of recent MI, DVT/PE, or any known
hypercoagulable state, many centers administer a time-limited
course (< 72 hours) of antifibrinolytic agent until the aneurysm
can be secured
• Early and LIMITED use (<72 hours) of these agents appear to be
safe

36. Pediatric Considerations
• Saccular aneurysmal SAH uncommon in children
• Dissecting and fusiform aneurysms associated with other medical co-morbidities
(sickle cell, moya-moya, connective tissues diseases) are more common than adults
• Infectious aneurysms from congenital or rheumatic heart conditions are more
common than in adults
• CT imaging in emergency, but if time allows MRI to limit radiation to developing brains
• LP if imaging negative and clinical concern
• Conventional angiography more difficult in children and may need to do in same
sitting after CTA/MRA
• Reasonable to aim for blood pressure as close to normal for age
• Nimodipine has been used in children, but role needs further clarification. Take care
to avoid hypotension
• Transfer to center with experience

37. Nursing Considerations
• Vigilant monitoring for signs and symptoms of hydrocephalus and
aneurysmal rebleed
• Pain should frequently be monitored and treated, with an effort to use non-
opioid medications to preserve level of consciousness
• In the presence increased ICP or unsecured aneurysm, nursing care should
be performed in intervals
• Patient should remain on bedrest when the aneurysm is unsecured, with
head of bed at least 30°
• Strict intake and output should be measured in patients who have had an
SAH, with efforts to keep patient euvolemic
• Close BP monitoring with dosing of nimodipine

38. Clinical Pearls
• Abrupt severe onset of headache (thunderclap headache)
• CT sensitivity in diagnosis is >90% (based on timing)
• LP should be done if CT is negative and history is strongly suggestive for
SAH. Xanthochromia and elevated RBC count (>2000 x 106/L RBCs) in
CSF is pathognomonic
• Control blood pressure to target SBP <160 mmHg
• Correct coagulopathy if present
• Treat hydrocephalus if present
• Monitor for rebleeding
• Aneurysm treatment within first 24 hours
• Initiate enteral nimodipine within 24 hours of admission

39. Communication
☐ Airway status
☐ Hemodynamic status and blood pressure control
☐ Clinical presentation (level of consciousness, motor exam, pupils)
☐ WFNS and Hunt-Hess Grade
☐ Imaging/LP results
☐ Coagulopathy present?
☐ Hydrocephalus present? If treated by EVD, provide drainage
goal/level
☐ Medications given (dose and time administered) including sedatives,
analgesics, seizure prophylaxis, anti-hypertensives, nimodipine
☐ Coordination of other vascular imaging

40. Questions?