This document discusses aneurysmal subarachnoid hemorrhage (SAH), including its causes, diagnosis, treatment, and complications. The most common cause is rupture of a cerebral aneurysm, which accounts for 80-85% of cases. Diagnosis involves CT scan and lumbar puncture to detect blood. Angiography is used to identify the aneurysm's location. Early securing of the aneurysm via coiling or clipping can prevent rebleeding and improve outcomes, which are also impacted by age, neurological grade, amount of bleeding, vasospasm severity and other factors. Complications include rebleeding, vasospasm, hydrocephalus, seizures, and medical issues.

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