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1. SUBARACHNOID HEMORRHAGE
SAH

2. SAH
• Extravasation of blood into the subarachnoid space
between the pial and arachnoid membranes
• Incidence: aneurysmal SAH 6-8/100.000

3. ETIOLOGIES
• Trauma: the most common cause
• Spontaneous:
- Ruptured intracranial aneurysms: 70-80%
- AVM: 4-5%
- Certain vasculitides involved the CNS
- Tumor: rarely
- Cerebral artery dissection ( post-traumatic):
carotid & vertebral artery

4. ETIOLOGIES
• Spontaneous:
- Rupture of a small superfacial artery
- Rupture of an infundibulum
- Coagulation disorders
- Dural sinus thrombosis
- Spinal AVM
- Pretruncal nonaneurysmal SAH
- Drugs, sickle cell anemia, pituitary apoplexy
- No cause: 14-22%

5. RISK FACTORS
• Hypertension
• Oral contraceptives
• Substance abuse: smoking, cocaine, alcohol
• Diurnal variations in BP
• Pregnancy & parturition
• Advancing age
• LP and/or cerebral angiography in patient with
cerebral aneurysm
• Conditions with an increased incidence of cerebral
aneurysms

6. CLINICAL FEATURES
• Symtoms: Severe H/A, voimiting, syncope, neck
pain, low back pain,photophobia, LOC, diplopia,
ptosis
• Signs: meningismus, hypertension, focal neurologic
deficit, coma, ocular hemorrhage

7. RADIOGRAPHIC FINDINGS
• CT-scan: detect > 95% of cases within 48 hrs of
SAH
• Assesses: ventricular size, hematoma, infarct,
amount of blood in cisterns & fissures, predict
aneurysm location

8. LUMPAR PUNCTURE
• The most sensitive test for SAH
• Xanthochromia and ghost cell
• >100000 RBCs/mm3
• Protein, glucose

9. RADIOGRAPHIC FINDINGS
• MRI: not sensitive in the first 24-48hrs
• FLAIR MRI: the most sensitive imaging study
for detecting blood in the subarachnoid space

10. RADIOGRAPHIC FINDINGS
• MRA: sensitive 87% , specificity 92%
• Assesses: aneurysm size, rate and direction of
blood flow, aneurysmal thrombosis and
calcification

11. RADIOGRAPHIC FINDINGS
• CTA: 97% Aneurysms
• Sfe and effective when used as the initial and
sole imaging study for ruptured and
unruptured cerebral aneurysms
• Evaluation of vasospasm

12. CEREBRAL ANGIOGRAM
• Gold standard
• 80-85%
• Assesses primary feeding arteries

13. Hunt & Hess 1968
GRADE Signs and symptoms Survival
1
Asymtomatic or minimal headache and slight neck stiffness 70%
2 Moderate to severe headache; neck stiffness; no neurologic deficit except
cranial nerve palsy
60%
3 Drowsy; minimal neurologic deficit 50%
4 Stuporous; moderate to severe hemiparesis; possibly early decerebrate
rigidity and vegetative disturbances
20%
5 Deep coma; decerebrate rigidity; moribund 10%

14. Fisher
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

15. The World Federation of Neurosurgeons
(WFNS)
GRADE 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

16. TREATMENT
• Calcium channel blockers
• Surgery
• Rebleeding: EACA, AMCA
• Activatad tissue plasminogen