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Subarachnoid Haemorrhage Management
- 1. SUBARACHNOID HEMORRHAGE Dr. Ashish Chowdhury Resident (Neurology), Phase B,BSMMU
- 2. Introduction Bleeding into the subarachnoid space (space between the pia & arachnoid meningeal layers where blood vessels lie & CSF flows.)
- 3. Introduction Less common than other types of stroke only 5% Affects about 6/100000 population Women more common Usually presents before 65 yrs Most commonly occurs between 40- 60 yrs
- 4. Immediate mortality : about 30% Recurrence: 40% in first 4 weeks, 3% annually
- 5. Risk factors Head injury Hypertension Female gender Alcohol abuse Cocaine abuse Family history Connective tissue disease PKD Fibromuscular dysplasia
- 6. Causes of Non Traumatic SAH • Ruptured berry aneurysm 85% • Non aneurysmal or perimesencephalic haemorrhage-10% • Rupture AVM • Vertebral Artery Dissection
- 7. Aneurysm • About 2% of adults harbor intracranial aneurysm. • Ruptured, Unruptured • Saccular,Mycotic,Fusiform,globular,Gaint,Diffuse • Most common locations are- Anterior Circulation Terminal ICA Bifurcation of MCA Top of the Basilar artery
- 8. Aneurysm • Size- 2mm to 3cm • Average size- 7.5mm • Those which rupture are usually 10mm or more but smaller ones can also get ruptured
- 9. Common sites of aneurysm
- 10. What causes the aneurysms to form? • Defects in the media of the arteries • Defects are thought to expand as a result of hydrostatic pressure from pulsatile blood flow and blood turbulence, which is greatest at the arterial bifurcations • Other theory says it is initiated by focal destruction of internal elastic membrane caused by hemodynamic forced acting at bifurcations & branching of arteries. As a result of local weakness in vessel wall intima bulges out covered only by adventetia
- 11. Clinical Feature Sudden severe thunderclap headache Often occipital Last for hours or even days Vomiting Antecedents – Physical exertion Straining Sexual excitement Loss of conciousness at onset
- 12. Distressed Irritable Photophobia Signs of meningeal irritation Seizure
- 13. Focal sign – If intracerebral haematoma Hemiparesis Aphasia 3rd CN palsy – Pcom 3rd 4th 6th CN palsy-Cavernous sinus Fundus - Subhyaloid hge,Papilloedema
- 14. Investigations • To diagnose SAH - High resolution non-contrast CT head - Lumbar puncture & CSF study - MRI brain • To identify the source - CT angiography - MR angiography - DSA
- 15. Investigations contd.. • Others: • Complete blood count • S. electrolytes, ABG: hyponatremia • PT, APTT: coagulopathy • Cardiac enzymes, ECG
- 16. • High resolution non-contrast CT detect SAH in almost 95% cases in first 3 days • Blood appears high density in subarachnoid space • After 5-7 days sensitivity decreases sharply • Also assesses ventricular size, infarct, hemorrhage • May predict aneurysm location based on pattern of blood • Anterior interhemispheric fissure- Acom • One sylvian fissure- Ipsilateral MCA or Pcom • Prepontine or peduncular cistern- Basilar top or SCA CT Scan
- 17. CT Scan
- 18. Basilar tip aneurysm rupture Unenhanced CT brain showing blood in basal cisterns & mild hydrocephalus
- 19. CT Scan contd.. Fisher grading for SAH on CT: • Grade 1 - No subarachnoid blood seen on CT scan • Grade 2 - Diffuse or vertical layers of SAH less than 1 mm thick • Grade 3 - Diffuse clot and/or vertical layer greater than 1 mm thick • Grade 4 - Intracerebral or intraventricular clot with diffuse or no subarachnoid blood
- 20. Lumbar Puncture • Usually done when CT is negative but strong clinical suspicion • Opening pressure: elevated • Non-clotting bloody fluids not clearing with sequential tubes • Xanthochromia • Yellowish coloration of CSF supernatent • Almost 100% sensitive after 12 hours, 40% at 4 weeks • Spectrophotometry is more sensitive than visual inspection • False negative: Jaundice, very high CSF protein
- 21. CSF color in SAH
- 22. MRI • Not sensitive in first 24-48 hours due to less methemoglobin • Better after 4-7 days for subacute hemorrhage • FLAIR & proton density images may be as sensitive as CT in acute stage • FLAIR, DWI, GRE, proton density sequences may help diagnosis in the second week when CT are being negative
- 23. A. GRE MRI after 10 days of SAH shows blood in left Sylvian fissure B. DSA shows a small aneurysm in left MCA bifurcation
- 24. Angiophraphy • CTA may detect aneurysm in 97% cases • MRA is 92% sensitive, 97% specific • For decision of type of repair, DSA is indicated • Sensitivity is less for aneurysm less than 3mm size • 10-15% SAH are angio-negative (perimesencephalic SAH) • Repeat angiogram may be needed 2-3 weeks later
- 25. Basilar tip aneurysm: before & after coiling
- 26. Diagnostic algorithm for SAH
- 27. Treatment Historical concept: • Strict BP control • Fluid restriction • Conservative approach & delay in specific management This approach was associated with high mortality & morbidity due to complications of hypovolemia, hypotension & rebleeding
- 28. Treatment • Initial stabilization & monitoring • Endovascular coiling or Surgical clipping • Prevention & treatment of complications
- 30. Treatment contd.. • Pt should be admitted in Neuro-ICU • Initial stabilization: Assess airway, breathing, circulation • Endotracheal intubation is indicated if the pt is in coma, depressed consciousness or unable to protect airway • Monitoring: • Cardiac monitoring • Pulse oximetry • Arterial BP monitoring • Urine output via catheter
- 31. • The focus in the first few minutes to hours after SAH, until the patient can undergo treatment of the ruptured aneurysm, should be directed toward the prevention of rebleeding. • This life-threatening complication, with a mortality rate of 20% to 60%, has its highest rate (8%to 23%) within the first 72 hours after SAH, with the majority of rebleeding (50% to 90%) occurring within the first 6 hours
- 32. HUNT AND HESS SCALE Grade 0: Asymptomatic Grade 1: Mild headache and mild nuchal rigidity, no neurological deficit Grade 2: Moderate to severe headache but no neurological deficit other than cranial nerve palsy Grade 3: Drowsy, confused, or mild focal deficit Grade 4: Stupor, moderate to severe hemiparesis, and early decerebrate posturing Grade 5: Deep comatose, decerebrate posturing
- 33. WORLD FEDERATION OF NEUROLOGICAL SURGEONS (WFNS) SCALE Glasgow coma scale Motor deficit Grade 0 15 Absent Grade 1 15 Present Grade 2 13–14 Absent Grade 3 13–14 Present Grade 4 7–12 Present or absent Grade 5 3–6 Present or absent
- 34. Blood Pressure Management • Early management is important to prevent rebleeding & to maintain cerebral perfusion pressure • Start antihypertensive agent if SBP>160 or MBP>130 mmHg • Target BP: SBP no more than 140 mmHg unless vasospasm • i.v. beta blocker labetalol, if no contra-indication, is the first choice because it has short half-life, is easily titratable & do not raise ICP • Nitroglycerine & nitroprusside raise ICP • ACE inhibitors are delayed acting
- 35. Treatment of aneurysm • With the publication of the ISAT, the treatment of an unsecured aneurysm has shifted from surgical clipping to mostly endovascular coiling. • ISAT showed that patients in the endovascular coiling group had significantly higher odds of survival free of disability 1 year after SAH and a lower risk of epilepsy when compared to the surgical clipping group. • Even 10 years after SAH, patients who underwent endovascular coiling had better outcome.
- 38. Endovascular & Surgical Treatment • Should be performed as early as possible in low to intermediate grade SAH (HHS or WFNS grade 1-3) • Severe grade pts may be candidate for delayed coiling or clipping • Endovascular coiling is preferred due to less complication • Follow-up vascular imaging is indicated • Retreatment should be considered by repeat coiling or clipping if there is clinically significant remnant
- 39. Coiling vs Clipping Endovascular treatment is favored over open surgery in the following situations: • Aneurysms in the posterior circulation because of the high surgical morbidity • Patients with higher-grade SAH (i.e. Hunt and Hess/WFNS grades 4-5) • Patients who are medically unstable • Patients with symptomatic cavernous aneurysms • Patients with vasospasm • Patients in whom the aneurysm lacks a defined surgical neck • Patients with multiple aneurysms in different arterial territories if the surgical risk is high
- 40. Coiling vs Clipping contd.. Clipping is favored in cases of: • Mass effect or large hematoma (>50 ml) associated with aneurysm • Large and giant aneurysm • MCA aneurysm • Wide-necked aneurysms - A large neck-to-dome ratio makes acute endovascular coiling of wide-necked aneurysms more difficult • Recurrent aneurysm after coil embolization
- 41. Complications of Coiling • Aneurysm rupture • Thromboembolism with acute or delayed neurologic deficit (stroke) • Coil displacement or compaction • Nonspecific access complications such as groin hematoma or arterial dissection
- 42. Management of neurological complications • Rebleeding • Hydrocephalus • Seizure • Delayed Cerebral Ischemia (DCI)
- 43. Rebleeding • Most dangerous complication • Risk is 60% in first 24 hour, 20 % at 14 days • Risk factors: • Large aneurysm • Poorly controlled BP • Higher Hunt & Hess grade • Delay in coiling or clipping • Use of antiplatelet
- 45. Rebleeding contd.. Prevention: • Bed rest in a quiet room • Analgesia, preferably with short acting agent e.g. fentanyl • Sedation, preferably with short acting agent e.g. midazolam • Stool softener • Management of BP • Early coiling or clipping • Antifibrinolytics reduce risk of rebleeding but increase risk of infarction: may be given for short term (<72 hours)
- 46. Vasospasm & Cerebral Ischemia • Occur 7-10 days after SAH & resolves spontaneously after 21 days • Amount of blood on initial CT is a good predictor • Hypovolemia & hypotension may precipitate vasospasm • Presents with new focal neurological deficit or global symptom • Prevention: • Avoid hypotension • Maintain euvolemia • oral nimodipine for 21 days- (60 mg every 4 hours for 21 days) • Monitoring: daily bedside transcranial Doppler USG
- 47. Vasospasm contd…
- 48. Vasospasm & Cerebral Ischemia contd.. Treatment of symptomatic vasospasm: • Triple H therapy: • Hypertension • Hypervolemia • Hemodilution. If bleeding site is not secured before, rebleeding may occur • Transluminal balloon angioplasty • Intra-arterial vasodilator therapy e.g. CCB, papaverine, Mg
- 49. Acute Hydrocephalus • Usually within first 24 hours • Occurs in 20% cases • Obstructive type • Blood in ventricles in initial CT is a good predictor • Presents with sudden neurologic deterioration • CT may differentiate from rebleeding • In obtunded pt, emergency ventriculostomy is needed
- 50. Chronic Hydrocephalus • After 10 days • 10-15% cases • Communicating type • Presents with, incontinence, ataxia, cognitive impairment • May be difficult to distinguish from vasospasm • Permanent CSF diversion (Shunt) may be needed
- 52. Seizure • Occur in 26% cases • Risk factors include hematoma, infarct, MCA aneurysm • Short term prophylaxis may be considered in high risk pts • Long term prophylaxis not recommended • Phenytoin, Levetiracetam is the agent of choice • Phenytoin i.v. can achieve rapid therapeutic concentration and it does not cause alteration in consciousness • Phenobarbital produces a sedative effect, which may mask the neurologic evaluation
- 53. Medical complications • Cardiorespiratory Dysfunction • Fever • Hyponatremia • Thromboembolism & prophylaxis • Glycemic Dysfunction
- 54. Hyponatremia • Occur in 10-30% cases • Cerebral salt wasting occur due to excess BNP • SIADH may also occur • CSW is hypovolemic, SIADH is euvolemic • Isotonic saline prevents hypovolemia, but not hyponatremia for which hypertonic saline may be needed
- 55. Cardiopulmonary dysfunction • Ranges from minor ECG changes to severe stress cardiomyopathy and neurogenic pulmonary edema. • The severity of SAH is an independent predictor of cardiopulmonary injury, • The cardiopulmonary injury is neurally mediated. • Cardiopulmonary complications after SAH are usually transient and resolve within several days to 2 weeks.
- 56. • Fever - most common medical complication( up to 70% of patients) - searching for infection & antipyretic • Glycemic Dysfunction: -current recommendations are to maintain a blood glucose level between 80 mg/dL and 200 mg/dL.
- 57. Deep vein thrombosis prophylaxis • All pt should have pneumatic compression stocking • UH can be used within 1-2 days following aneurysms treatment • IVC filter if DVT or PE occurs after clipping • Systemic anticoagulation if DVT or PE occurs after coiling..
- 58. Reference • CONTINUUM (MINNEAP MINN) 2018;24(6, NEUROCRITICAL CARE): 1623–1657. • Harrison's Principles of Internal Medicine, Twentieth Edition. • Adams and Victor's Principles of Neurology 11th Edition
- 59. THANK YOU