Subarachnoid Hemorrhage

Basis

Signs and Symptoms of the Patient Clinical Manifestation

 1 month prior to admission, patient
complained of intermittent episodes of
mild to moderate headache with
dizziness occurring throughout the
month precipitated by activity like
walking and relieved by rest.
 unresponsive, conscious with right sided
paralysis on both upper and lower
extremities, drooping of the right side of
the face
 Sudden loss of consciousness may be
preceded by a brief moment of excruciating
headache, but most patients first complain of
headache upon regaining consciousness
 severe headache associated with exertion is
the presenting complaint.
 ruptures may present as headache of only
moderate intensity or as a change in the
patient’s usual headache pattern
 headache is usually generalized, often with
neck stiffness, and vomiting is common.
 Anterior communicating artery or MCA
bifurcation aneurysms may rupture into the
adjacent brain or subdural space and form a
hematoma large enough to produce mass
effect. The deficits that result can include
hemiparesis, aphasia, and mental slowness
(abulia).
 More than one third of patients give a history
of a premonitory, “sentinel headache” in the
days to weeks before presenting with
subarachnoid hemorrhage. These prodromal
symptoms are usually caused by minor leaks
of blood from the aneurysm, but they also
may be caused by acute thrombosis or
expansion of an aneurysm

Pathophysiology

Pathophysiology Saccular aneurysms occur at the bifurcations of the large- to medium-sized intracranial
arteries; rupture is into the subarachnoid space in the basal cisterns and sometimes into the
parenchyma of the adjacent brain. Approximately 85% of aneurysms occur in the anterior circulation,
mostly on the circle of Willis. About 20% of patients have multiple aneurysms, many at mirror sites
bilaterally. As an aneurysm develops, it typically forms a neck with a dome. The length of the neck and
the size of the dome vary greatly and are important factors in planning neurosurgical obliteration or
endovascular embolization. The arterial internal elastic lamina disappears at the base of the neck. The
media thins, and connective tissue replaces smooth-muscle cells. At the site of rupture (most often the
dome), the wall thins, and the tear that allows bleeding is often ≤0.5 mm long. Aneurysm size and site
are important in predicting risk of rupture. Those >7 mm in diameter and those at the top of the basilar
artery and at the origin of the posterior communicating artery are at greater risk of rupture.
 Laboratory and Imaging

CSF noncontrast CT scan four-vessel conventional x- CT angiography

ray angiography
 The hallmark of  More than 95% of cases Once the diagnosis of  CT angiography is an
aneurysmal rupture is have enough blood to be hemorrhage from a alternative method for
blood in the visualized on a high-quality ruptured saccular locating the aneurysm and
cerebrospinal fluid (CSF). noncontrast CT scan aneurysm is suspected, may be sufficient to plan
 If the scan fails to obtained within 72 h. four-vessel definitive therapy.
establish the diagnosis of conventional x-ray
SAH and no mass lesion angiography (both
or obstructive carotids and both
hydrocephalus is found, a vertebrals) is generally
lumbar puncture should performed to localize
be performed to and define theanatomic
establish the presence of details of the aneurysm
subarachnoid blood. Lysis and to determine if
of the red blood cells and other unruptured
subsequent conversion of aneurysms exist
hemoglobin to bilirubin
stains the spinal fluid
yellow within 6–12 h.
This xanthochromic
spinal fluid peaks in
intensity at 48 h and lasts
for 1–4 weeks,
depending on the
amount of subarachnoid
blood
 Lumbar puncture prior to
an imaging procedure is
indicated only if a CT
scan is not available at
the time of the
suspected SAH.
 Management

Treatment Goals
protecting the airway, managing blood pressure before and after aneurysm treatment, preventing rebleeding prior to
treatment, managing vasospasm and DCI, treating hydrocephalus, treating hyponatremia, limiting
secondary brain insults, and preventing pulmonary embolus (PE).