This document discusses the differences between traumatic (tSAH) and spontaneous (sSAH) subarachnoid hemorrhage. It notes that while tSAH is usually caused by head trauma, sSAH is often due to a ruptured brain aneurysm. The clinical presentations can overlap but differentiation is important for determining treatment, which involves securing the airway, managing increased intracranial pressure, and treating the underlying cause such as clipping an aneurysm. While management principles are often similar, the definitive treatment differs based on the etiology of subarachnoid hemorrhage.

1. Traumatic Vs Spontaneous
Subarachnoid Hemorrhage (SAH)
Dr Amit Agarwal
Professor of Neurosurgery
Narayana Medical College and Hospital
Nellore (AP)

2. • Conflict of interest: None
• Financial support: Nil
Disclosures

3. • Many more conditions
Trauma first or pathology first
Seizures Trauma
Loss of consciousness Trauma
Intracranial hemorrhage Trauma
Focal weakness Trauma

4. • It can be spontaneous
• It can be traumatic
• Spontaneous SAH can lead to trauma
(aneurysmal rupture while driving)
• Rupture of traumatic aneurysms can lead to
SAH
Puzzle of spontaneous versus
traumatic SAH

5. • What is subarachnoid space?
• What is SAH?
• What are the causes of SAH?
• What are the clinical features?
• How to make a diagnosis?
• How to plan the management?
First thing first
"The eye cannot see what the mind does not know”

6. What is subarachnoid space?

7. • Subarachnoid Hemorrhage (SAH) is a
collection of blood into the subarachnoid
space
• Common source is arteries (ruptured
aneurysm or arteial tears) traversing through
the subarachnoid space
What is SAH?

8. • Traumatic SAH (26-53% of all trauma cases)
• Spontaneous SAH
– Spontaneous rupture of an aneurysm (80-85%)
• Many other diseases
– Cerebral amyloid angiopathy
– Arteriovenous malformation
– Septic aneurysm
– Cocaine associated SAH
– Moya-moya disease
– Sickle cell disease
– Pituitary apoplexy
– Vertebral dissection
– Carotid dissection
Causes of SAH

9. Clinical presentation
sSAH tSAH
Headache Sudden severe
headache
Thunderclap headache
Worst headache ever
varying severity
Sentinel headache ✓ ✕
Altered consciousness ✓ ✓
Confusion and irritability ✓ ✓
Nausea and vomiting ✓ ✓
Meningeal irritation ✓ Please do not elicit neck rigidity
Seizures ✓ ✓
Neurological deficits ✓ ✓
Retinal hemorrhages ✓ ✓
Trauma  ✓

10. • Elaborate clinical history
• A complete neurological evaluation
– Level of consciousness
– Pupillary examination
– Reflexes
– Motor response
– Clinical history
– Examination
• Look for signs of injuries including C-spine
• Imaging appearance
• A high index of suspicion
Algorithm to approach

11. Investigations: Non-contrast CT scan
• Initial investigation of choice
– Presence of SAH
– Distribution of blood
– Extent of hemorrhage
– Any associated lesions

12. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 33934
Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 4852

13. • Angiography
– CTA
– DSA
– MRA
• Lumbar puncture (Please rule out any
intracranial mass lesions)
Further investigations

14. Management
sSAH tSAH
Airway ✓ ✓
Breathing ✓ ✓
Circulation ✓ ✓
Disability assessment ✓ ✓
Anti-epileptics ✓ ✓
Supportive management ✓ ✓
Management of raised ICP ✓ ✓
Management of vasospasm ✓ ✓
Euvolemia ✓ ✓
Normothermia ✓ ✓
Treatment of underlying etiology Aneurysm clipping

15. • Even though etiological classification
categorizes traumatic and non-traumatic or
spontaneous (SAH) separately, in many
aspects the clinical presentation and
management significantly overlaps
• However, differentiation between tSAH and
sSAH is important as the definitive treatment
is not same
Conclusions

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