etiology and mangement of SAH and berry anuerysm

1. SUBARACHNOID
HAEMORRHAGE
1
Presented by :
Shambhavi Sharma
Intern
Surgery Department
KISTMCTH

2. 2
INTRODUCTION

3. SUBARRACHNOID HAEMORRHAGE
• Hemorrhage in the
subarachnoid space
• SAH is a neurological
emergency
• Less common but an
important cause of stroke
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4. Epidemiology
9.7-14.5 per 100,000 population
• peak age for aneurismal SAH is 55–60 years, ≈
20% of cases occur between ages 15–45 yrs
• higher in women (1.24 times higher than men)
• higher in African Americans(2.1 times higher
than whites)
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5. Risk factors
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6. SAH- etiology
• CLASSIFIED AS: TRAUMATIC
NON TRAUMATIC
• Excluding head trauma, the most common cause of
SAH is rupture of a SACCULAR ANEURYSM.
• Other causes :
 bleeding from a vascular malformation (AV malformation
or dural AV fistula )
 Extension into the subarachnoid space from a primary
intracerebral haemorrhage.
 Mycotic aneurysms
 Associated with genetic disorders 6

7. Mechanism of formation of aneurysms
 developmental defect in the media & elastica
 focal destruction of internal elastic membrane
caused by hemodynamic forces acting at
bifurcations & branching of arteries
local weakness in vessel wall, intima bulges out
covered only by adventitia
The sac gradually enlarges and subsequently rupture
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9. SACCULAR ("BERRY") ANEURYSM
• Autopsy and angiography studies have found that
about 2% of adults harbor intracranial aneurysms,
• Size- 2 mm. to 2-3 cm
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13. PATHOPHYSIOLOGY
• Saccular aneurysms occur at the bifurcations of the large to
medium-sized intracranial arteries.
Rupture is into the
 subarachnoid space,
 basal cisterns
 the parenchyma of the adjacent brain.
• Approximately 85% of aneurysms occur in the
anterior circulation, mostly on the circle of Willis.
• About 20% of patients have multiple aneurysms,
- - many at mirror sites bilaterally.
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CLINICAL MANIFESTATIONS-

16. • Aneurysms can undergo small ruptures and blood leaks into the
subarachnoid space, so-called SENTINEL BLEED.
SYMPTOMS are usually due to rupture of aneurysm and resultant SAH
• some present with mass effect on cranial nerves or brain
parenchyma.
• Aneurysmal rupture usually occurs while the pt is active
• may occur while straining on stool, sexual intercourse, lifting a heavy
weight or some other sustained exertion
• 30% of aneurysmal SAHs occurs during sleep
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17. Four patterns of presentations:
 Pt. is stricken with severe headache & vomiting , and falls
unconscious immediately
 Severe generalized headache occurs suddenly but pt remains
lucid with varying degrees of neck stiffness
 Rarely pt suddenly becomes unconscious without any preceding
complaint.
 patient may die within min to hours
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18. • In patients who survive initial rupture the most
feared complication is rerupture which may
occur at any time from minutes to 2-3 wks
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19. HEADACHE
In ~45% of cases,sudden onset severe headache
associated with exertion is the presenting
complaint.
"the worst headache of life";
 usually generalized,
often with neck stiffness,
vomiting is common
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20. Pain at other sites
• Occipital and posterior cervical pain may
signal a posterior /anterior inferior cerebellar
artery (PICA/AICA) aneurysm.
• Pain in or behind the eye and in the low
temple can occur with an expanding MCA
aneurysm
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21. Loss of consciousness
• sudden transient loss of consciousness in
nearly half of patients
• 6-16% patients develop seizures
• In 10% of cases, aneurysmal bleeding is severe
enough to cause loss of consciousness for
several days.
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22. Ocular hemorrhage
• Due to compression of central retinal vein and
retrochoroidal anastomoses by elevated CSF
pressure causing venous hypertension and
disruption of retinal veins
• Occurs in 20-40% of patients
• Types: subhyaloid/preretinal hemorrhage
intraretinal hemorrhage
Viterous hemorrhage(Terson syndrome)
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23. FOCAL NEUROLOGICAL DEFICITS
• ACA or MCA bifurcation aneurysms may rupture
into the adjacent brain or subdural space and form
a hematoma large enough to produce mass effect.
hemiparesis,
aphasia,
progressive drowsiness or slow mentation
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24. • Third nerve palsy : aneurysm at the junction
of post. Communicating & post. Cerebral
arteries
• A sixth nerve palsy: an aneurysm in the
cavernous sinus
uni or bilateral palsy could be because of raised
ICP
• Unilateral blindness : aneurysm lying
anteromedially in the circle of willis usually at
the origin of opthalmic artery
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25. Transient paresis of one or both lower limbs :
ant comunicating A. aneurysm that has interfered
with circulation in ant. Cerebral arteries.
Hemiperesis or aphasia suggests aneurysm at the first
bifurcation of middle cerebral artery
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26. D/D severe headache
 Migraine headache
 ingestion of sympathomimetic drugs
 ingestion of tyramine containg foods in a pt. who is taking
MAO inhibitors
 phaeochromocytoma
 Cerebral venous thrombosis,
 Diffuse vasospasm (call-flemming syndrome),
 Hypertensive encephalopathy,
 Intracranial or extracranial arterial dissection
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27. DELAYED NEUROLOGIC DEFICITS
1. RERUPTURE/REBLEED,
2.HYDROCEPHALUS
3.VASOSPASM
4.HYPONATREMIA.
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28. Signs of meningism
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Body system involved complications
Volume status,electrolyte
and metabolic disturbance
Hypovolemia,hyponatremia,hyperglycemi
a,hypokalemia
Cardiac complications ECG Changes,myocardial
ischaemia,elevated troponin,systemic and
pulmonary
hypertension,arrythmias,neurogenic
stunned myocardial syndrome
Pulmonary complications Neurogenic pulmonary
edema,aspiration,pneumonia

30. Investigations
1.diagnose SAH: non contrast CT Scan
2.identify source of SAH: CT
angiography,MR angiography, catheter
angiography
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31. NON CONTRAST CT SCAN.
• CT Scan is Initial investigative procedure
More than 95% of cases have enough blood to be
visualized on a high-quality NONCONTRAST CT
SCAN obtained within 48 h.
 locate the underlying aneurysm,
 identify the cause of any neurologic deficit, and
 predict delayed vasospasm
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35. MRI
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36. lumbar puncture
• Usually CSF becomes grossly bloody within 30 minutes of bleed with
RBC counts upto 1 million/c mm or more
• Lysis of the red blood cells and subsequent conversion of
hemoglobin to bilirubin stains the spinal fluid yellow( xanthochromia)
within 2-4 h max by 12 hrs
• lasts for 1–4 weeks, depending on the amount of subarachnoid
blood
• Protein: high due to blood breakdown products
• Glucose: normal or reduced
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37. Angiography
CT angiography
• for locating the aneurysm and its relation with nearby
bony structures
• Evaluation of vasospasm
MR angiography
87% sensitive 92% specific
Catheter angiogram
GOLD STANDARD
Demonstrates source in 80-85% cases
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41. IMAGING STUDIES
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42. OTHER INVESTIGATIONS
Close monitoring (daily or twice daily) of
electrolytes : hyponatremia occur
precipitously during the first 2 weeks following
SAH
An asymptomatic troponin elevation is
common.
ECG
ECHO
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43. TREATMENT
The medical management of SAH focuses on
• Managing blood pressure and maintaining
euvolemia
• Maintaining ICP
• Preventing rebleeding prior to treatment,
• Managing vasospasm, delayed neurological deficits
• managing seizures
• Treating hydrocephalus,
• Treating hyponatremia,
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44. • bed rest in a quiet room
• stool softeners to prevent straining.
• If Headache or neck pain is severe, mild sedation
and analgesia
• Extreme sedation is avoided because it can obscure
changes in neurologic status.
• Adequate hydration
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45. Prevention of vasospasm
• Calcium channel blockers: oral nimodipine
should be administered in all patients with
aSAH
• Maintainance of euvolemia and normal
circulating volume
• Induction of hypertension is recommended for
patients with DCI unless BP is elevated at
baseline
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46. POST SAH SEIZURES
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• Prophylactic anticonvulsant may be considered in
immediate post hemorrhagic state
• Routine long term use of anticonvulsant is not
recommended
• long term use of anticonvulsant may be
considered in patients with risk factors for deayed
seizure disorder (prior seizure, intracerebral
hematoma, intractable hypertension,infarction,or
MCA aneurysm)

47. Antifibrinolytic therapy
• For patients with aneurismal SAH where:
1. unavoidable delay in t/t of aneurysm
2.pt with significant risk of re bleeding
3. no compelling medical contraindications
Upto 72 hrs of therapy with tranexemic acid or
aminocaproic acid is reasonable
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48. Acute hydrocephalus
• CSF diversion or lumbar drain
Chronic hydrocephalus
Permanent CSF diversion for symptomatic
patients
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49. INTERVENTIONAL MANAGEMENT
• Early aneurysm repair prevents
rerupture/rebleeding and
 allows the safe application of techniques to
improve blood flow (e.g., induced hypertension
and hypervolemia) should symptomatic vasospasm
develop.
• An aneurysm can be "clipped" or "coiled”
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50. Angiographic findings: general features to take note
when analysing anuerysm
1.size of aneurysm dome
2.neck size
3.dome neck ratio
 Large aneurysms > 15 mm diameter are a/w lower rates
of complete occlusion by endovascular coiling
 Narrow neck <5 mm are ideal for coiling
 Broad neck > 5mm a/w increased risk of incomplete
occlusion and recanalization by coiling
 Stent or balloon assisted coiling may be needed for wide
necked aneurysm
 Dome neck ratio : > or equal to 2 are a/w higher rate of
successful coil occlusion 6
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SURGICAL REPAIR
•Involves placing a metal clip across the aneurysm
neck, thereby immediately eliminating the risk of
rebleeding.
•This approach requires craniotomy and brain
retraction, which is associated with neurologic
morbidity.

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Add another grade for serious illnesses,or evidence of vasospasm in CT angiography

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58. Management based on HH scale
Grades 1 & 2
• Current approach is to go for intervention within 24 hrs
This will prevent rebleed and will allow measures to be taken to
improve cerebral circulation
• Grade 3 patients- if their condition allows , they too would be
benefitted by the procedure
• Grade4/5- the outcome is generally poor but by putting a ventricular
drain and improving the grade, pt are sometimes taken for
intervention
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Endovascular techniques
involve placing platinum coils,
or other embolic material,
within the aneurysm via a
catheter that is passed from
the femoral artery.

67. NEWER DRUGS
• Magnesium
• Statins
• Endothelin receptor antagonist
• Tirilizad
• Erythropoietin
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68. References
• Bailey and love’s Short Practice of Surgery,26th
edition
• AHA/ASA guideline for management of
aneurysmal suarachnoid hemorrhage, june
2012
• Giovanni Grasso, et al authors, Management
of aneurysmal SAH : state of the art and
future perspectives, surgical neurology
international ,2017
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