Subarachnoid Hemorrhage (SAH) is a type of stroke caused by bleeding into the subarachnoid space surrounding the brain. The leading cause is a ruptured aneurysm, which accounts for 75% of cases. SAH presents with an extremely severe headache, neck stiffness, nausea, and sometimes decreased consciousness. Diagnosis is confirmed through CT scan or lumbar puncture. Treatment focuses on controlling blood pressure, preventing rebleeding, and reducing complications like hydrocephalus and cerebral vasospasm.

1. Subarachnoid Hemorrhage
(SAH)
Ionuţ Cărăvan
Coordinated by Prof. Ioan Ştefan Florian, MD, PhD
University of Medicine and Pharmacy
“Iuliu Haţieganu“ Cluj Napoca

2. Definition
• SAH = extravasation of blood into the subarachnoid
space

3. Etiology
Greenberg Handbook of Neurosurgery, 2010
 Traumatic SAH
 Non-traumatic (spontaneous) SAH
oruptured intracranial aneurysms (75 %)
oAVM (5 %)
oothers (tumor, vasculitis, coagulation disorders, dural
sinus thrombosis)
ounknown etiology (15 %)=“angiogram-negative SAH”

4. Presenting features(1)
• HEADACHE (“thunderclap headache”)
• meningismus
 neck stiffness
 photophobia
 back pain

5. Presenting features(2)
• decreased state of consciousness
• nausea and vomiting
• seizures
• focal neurologic deficits:
 oculomotor palsy
 hemiparesis
• ocular hemorrhage

6. Radiographic findings
• CT scan
• Cerebral Angiography
• FLAIR* MRI
• CT Angiography
• MRA**
*Fluid-attenuated inversion recovery
**Magnetic Resonance Angiography

7. CT scan

8. Lumbar puncture

9. Grading SAH
Hunt and Hess Grade WFNS* Grading
*World Federation of Neurological Surgeons

10. Complications
• Hydrocephalus
• Vasospasm => delayed cerebral ischemia
• Seizures
• Rebleeding
• Intracerebral hemorrhage
• Intraventricular hemorrhage
• Left ventricular systolic dysfunction
• Subdural hematoma

11. Treatment
• BP control (fluid restriction and antihypertensive therapy) when the
mean arterial pressure exceeds 130 mm Hg
• ICP control (osmotic agents, loop diuretics)
• Symptomatic treatment:
– anticonvulsants: levetiracetam, phenytoin
– analgesics: fentanyl
– anti-emetics: odansetron
– calcium channel blockers: nimodipine, verapamil => vasospasm
!!! Prevention of rebleeding:
• antifibrinolytic therapy
• surgical treatment
• endovascular treatment

12. References
• MS Greenberg. Handbook of Neurosurgery. Seventh Edition.
New York: Thieme Medical Publishers; 2010.
• AH Kaye. Essential Neurosurgery. Third Edition. Oxford:
Blackwell Publishing Ltd; 2005.
• MG Yasargil. Microneurosurgery. New York: Thieme Medical
Publishers Inc; 1994.

13. Thank you!