Subarachnoid hemorrhage (SAH) is characterized by blood in the subarachnoid space, commonly resulting from aneurysm rupture, with a peak incidence in individuals aged 55-60 years. It is often preceded by a sentinel headache and can lead to severe complications such as hydrocephalus and delayed cerebral ischemia. Diagnosis is primarily through CT scans, lumbar puncture, and angiography to identify potential aneurysms.

1. SUBARACHNOID
HEMORRHAGE
Chester H, Jardiolin, MD, FPSNS, FICS, MHM
Neurosurgery

2. Question:
What is
Subarachnoid
Hemorrhage?

3. SUBARACHNOID HEMORRHAGE
● Blood in the
subarachnoid space,
between the
arachnoid membrane
and the pia mater

4. REVIEW OF ANATOMY

5. MISCELLANEOUS FACTS
Trauma is the most common cause
MAY BE POSTTRAUMATIC OR SPONTANEOUS
1
ANEURYSM RUPTURE
Most cases of SAH are due to
aneurysm rupture
2
Peak age for aneurysmal SAH is 55 -
60 years, = 20 % of cases occurs
between ages 15 - 45 years
55 - 60 years
3
ABOUT SUBARACHNOID HEMORRHAGE

6. MISCELLANEOUS FACTS
30% of aneurysmal SAHs occur during sleep
SLEEP
4
SENTINEL HEADACHE
Sentinel headache thats that precede the
SAH - associated ictus have been reported
by 10 - 50% of patients and most commonly
occur within 2 - 8 weeks before overt SAH
5
Most to the side of the aneurysm
HEADACHE IS LATERALIZED IN 30 %
6
ABOUT SUBARACHNOID HEMORRHAGE

7. MISCELLANEOUS FACTS
Intracerebral hemorrhage in 20 - 40%, by
intraventricular hemorrhage in 13 - 28% and by
subdural blood in 2 - 5 % usually due to posterior
communicating aneurysm when over convexity, or
distal anterior intracerebral artery (DACA) aneurysm
with interhemispheric subdural hematoma
IT IS COMPLICATED BY
7
May occur in up to 20% of patients after
SAH, most commonly in the first 24 hours
and are associated with ICH, HTN and
aneurysm location
SEIZURES
9
ABOUT SUBARACHNOID HEMORRHAGE
≥ 70 YEARS OF AGE
Have a higher proportion of with a severe
neurologic grade
8

8. CIRCLE OF WILLIS

9. INCIDENCE AND PREVALENCE
OF SUBARACHNOID HEMORRHAGE
● Estimated annual rate
of aneurysmal SAH in
the United States:
9.7-14.5 per 100,000
population.
● Reported rates are
lower in South and
Central America, and
higher in Japan and
Finland
● Incidence of SAH increases
with age; tends to be higher
in women (1.24 times
higher than men) and
appears to be higher in
African Americans and
Hispanics (compared to
Caucasians)

10. RISK FACTORS AND PREVENTION
OF ANEURYSMAL SUBARACHNOID HEMORRHAGE
01
Hypertension
Cigarette Smoking
Alcohol Abuse
Sympathomimetic
drugs such as Cocaine
BEHAVIORAL
03
Ruptured aneurysm
Unruptured aneurysm
Morphology: Bottleneck shape and increased ratio of size of
aneurysm to parent vessel have been associated with
increased risk of rupture
HISTORY OF
CEREBRAL
ANEURYSM
04
At least 1 first degree family
member and especially of > 2 are
affected
FAMILY HISTORY
OF ANEURYSM
05
ADPKD
Type IV Ehler Danlos Syndrome
GENETIC
SYNDROMES
06
There does not appear
to be an increased risk
of aneurysmal SAH in
pregnancy , delivery
and puerperium
PREGNANCY
02 GENDER AND
RACE

11. CLINICAL FEATURES
SYMPTOMS AND SIGNS OF SUBARACHNOID HEMORRHAGE
HYPERTENSION
● Subarachnoid hemorrhage including “warning
headache” or sentinel headache
● Benign “thunderclap” headache or crash
migraine
● Reversible cerebral vasoconstriction syndrome
● Airplane headache; usually sudden, often with
onset during take-off or landing of aircraft;
short-lasting
● Benign Orgasmic Cephalgia: a severe,
throbbing, sometimes explosive H/A with onset
just before or at the time of orgasm.
SUDDEN ONSET OF SEVERE H/A, USUALLY
WITH VOMITING, SYNCOPE (APOPLEXY), NECK
PAIN (MENINGISMUS), AND PHOTOPHOBIA.
MENINGISMUS
Kernig sign
Brudzinski sign

12. OCULAR HEMORRHAGE
Subhyaloid
Intra (Retinal hemorrhage)
Hemorrhage within the vitreous humor
(Terson Syndrome)
Oculomotor Palsy
Hemiparesis
FOCAL NEUROLOGICAL
DEFICIT
COMA FOLLOWING SAH
Increased ICP
Damage to brain tissue from
intraparenchymal hemorrhage
Hydrocephalus
Diffuse ischemia
Seizure
Low blood flow
CLINICAL FEATURES
SIGNS OF SUBARACHNOID HEMORRHAGE
OBTUNDATION OR COMA

13. WORKUP
OF SUSPECTED SUBARACHNOID HEMORRHAGE
● Non contrast high
resolution CT scan
● If CT scan is negative: LP
in suspicious cases
TESTS TO DIAGNOSE SAH
● CTA, MRA or Catheter Angiography
● MRA: No radiation and 2D TOF MRA
does not use contrast; Poor
sensitivity for aneurysm detection
early after SAH
● CTA vs Angiogram: One needs to
balance the risk of the procedure
and ease of obtaining it against the
information expected to be
obtained
TESTS TO IDENTIFY
SOURCE OF SAH
● If CTA or Angiogram is
negative
SAH OF UNKNOWN
ETIOLOGY
SUBARACHNOID HEMORRHAGE

14. Question:
How do we
confirm the
diagnosis of SAH?

15. CT SCAN
DIAGNOSTICS
● A good quality non-contrast high-resolution CT
will detect SAH in ≥95% of cases if scanned
within 48 hours of SAH.
● Ventricular size: hydrocephalus occurs acutely
in 21% of aneurysmal ruptures
● Hematoma: intracerebral hemorrhage or large
amount of subdural blood with mass effect
may need emergent evacuation
● Infarct : not sensitive in first 24 hours after
infarct
● Amount of blood in cisterns and fissures:
important prognosticator for vasospasm
● CT can predict aneurysm location based on the
pattern of blood
● With multiple aneurysm
CT also assess the following:

18. DIFFERENTIAL DIAGNOSIS
OF SUBARACHNOID HEMORRHAGE ON CT
PUS FOLLOWING CONTRAST
ADMINISTRATION:
SOMETIMES IV AND
ESPECIALLY
INTRATHECAL
OCCASIONALLY THE
PACHYMENINGEAL
THICKENING SEEN IN
SPONTANEOUS
INTRACRANIAL
HYPOTENSION
SUBARACHNOID HEMORRHAGE

19. Question:
What is the gold
standard in diagnosis
of Subarachnoid
Hemorrhage?

20. LUMBAR PUNCTURE
● Most sensitive test for SAH.
● However, false-positives (e.g. with traumatic taps)
occur with enough frequency that this test is
falling out of favor for the diagnosis of SAH
● Findings in lumbar puncture:
○ Opening pressure: Elevated
○ Appearance:
■ Non-clotting bloody fluid that does not clear with
sequential tubes
■ Xanthochromia: yellow coloration of CSF
supernatant
○ Cell count: RBC count usually > 100,000 RBCs/mm3
○ Protein: elevated due to blood breakdown products
○ Glucose: normal or reduced

21. MAGNETIC RESONANCE IMAGING MAGNETIC RESONANCE ANGIOGRAPHY
● Not sensitive for SAH acutely within the
first 24 - 48 hours, especially within the
layers of blood
● Sensitivity is 87% and specificity is 92%
for detecting intracranial aneurysms
compared to catheter DSA with
significantly poorer sensitivity for
aneurysms < 3mm diameter
DIAGNOSTICS
OF SUBARACHNOID HEMORRHAGE

22. CT ANGIOGRAPHY (CTA)
● Many centers have shown good
results with CTA with a
prospective study detecting
97% aneurysms and
demonstrating CTA as safe and
effective when used as the
initial and sole imaging study
for ruptured and unruptured
cerebral aneurysms.

23. CATHETER ANGIOGRAM
● The gold standard for evaluation of cerebral aneurysms. Current state of the art uses
digital subtraction angiography (DSA).
● General principles:
○ Study the vessel of highest suspicion first
○ Continue to do complete 4 vessel angiogram
○ If there is an aneurysm or suspicion of one, obtain additional vies to help delineate the neck and orientation
of the aneurysm
○ If no aneurysm is seen
■ Visualize both PICA origins
■ Flow contrast through the ACoA
■ If an infundibulum colocalizes to the SAH, it may be unwise to label the case as angiogram-negative
and exploration is recommended by some.

24. INFUNDIBULUM
● A funnel shaped initial segment of an
artery, to be distinguished from an
aneurysm
● Most commonly found at the origin of
the p-comms
● May represent incomplete remnants of
previous fetal vessels.

25. ANGIOGRAPHIC FINDINGS
● General features to take note of when
analyzing an aneurysm on angiogram:
○ Size of aneurysm dome
○ Neck size
■ Narrow necks <5 mm are ideal for
coiling
■ Broad neck ≥ 5 mm are associated
with increased risk of incomplete
occlusion and recanalization with
coiling
■ Stent or balloon-assisted coiling may
be needed for wide necked
aneurysms. Stents should be avoided
if possible.
○ Dome neck ratio ≥ 2 is associated with
higher rate of successful coil occlusion

26. GRADING SAH
HUNT AND HESS GRADE
Grade Description
1 Asymptomatic , or mild H/A and slight nuchal rigidity
2 CN Palsy (e.g. III, VI), moderate to severe H.A, nuchal rigidity
3 Mild focal deficit, lethargy, or confusion
4 Stupor, moderate to severe hemiparesis, early decerbrate rigidity
5 Deep coma, decerebrate rigidity, moribund appearance
Add on grade for serious systemic disease or severe vasospasm on arteriography

27. GRADING SAH
WFNS SAH GRADING
WFNS Grade GCS score Major focal deficit
0
1 15 -
2 13-14 -
3 13-14 +
4 7-12 +/-
5 3-6 +/-

28. HYDROCEPHALUS AFTER SAH
● The frequency of hydrocephalus depends on the defining criteria used, with a reported range
of 9-67%.
● Factors include blood interfering with CSF flow through the Sylvian aqueduct, fourth ventricle
outlet, or subarachnoid space, and/or with reabsorption at the arachnoid granulations.
● Findings associated with acute HCP include:
○ Increasing age
○ Admission of CT findings: intraventricular blood, diffuse subarachnoid blood, and thick focal accumulation of
subarachnoid blood
○ Hypertension
○ By location:
■ Posterior circulation aneurysms have a higher incidence of HCP
■ MCA aneurysms correlated with low incidence of HCP
○ Miscellaneous: hyponatremia, patients who were not alert on admission, use of preoperative antifibrinolytic agent and
low Glasgow outcome source.

30. INTRODUCTION
● aSAH is a significant cause of morbidity and mortality throughout the world
● A quarter of patients with aSAH die, and roughly half of survivors are left with
some persistent neurological deficit.
● Case-fatality rates appear to be falling
● Increasing data suggest that early aneurysm repair, together with aggressive
management of complications such as hydrocephalus and delayed cerebral
ischemia (DCI) leads to improved functional outcomes.
● Large, multicenter, randomized trial data confirming effectiveness are usually
lacking for many of the interventions discussed.

31. AIMS AND OBJECTIVES
● The aim of this guideline is to present current and comprehensive
recommendations for the diagnosis and treatment of aneurysmal
subarachnoid hemorrhage (aSAH)

32. APPLYING CLASSIFICATION OF RECOMMENDATION AND LEVEL OF EVIDENCE

33. DEFINITION OF CLASSES AND LEVEL OF EVIDENCE

34. SUBCATEGORIES INCLUDED
● Incidence
● Risk factors
● Prevention
● Natural history and outcome
● Diagnosis
● Prevention and rebleeding
● Surgical and endovascular repair of ruptured aneurysms
● Systems of car
● Anesthetic management during repair
● Management of vasospasm and DCI
● Management of hydrocephalus
● Management of seizures
● Management of medical complications

35. RESULTS

40. CASE:
General Data: JG, 32 year old, Male
NOI: MVC
TOI: 12 AM
POI: January, Iloilo
DOI: 04/07/23
CC: Vomiting
HPI:
15 hours PTA, patient was driving a motorcycle when he suddenly fell asleep causing him to
fall from his vehicle.
12 hours PTA, bystanders saw him and called an ambulance. Patient was unconscious until
ambulance arrived and brought him to the health center where first aid was administered.
10 hours PTA, patient had 2 episodes of vomiting, dizziness and complained of pain in the
back of his neck.

44. THANK YOU