Subarachnoid Haemorrhage Dr. Jonathan Yang Neurosurgery

SAH Sudden onset of severe headache  SAH until proven otherwise !!! 5-10% of all non-traumatic intracranial haemorrhage 15/100000 population

Aetiology Most common one for Adults  Rupture of a berry aneurysm 70% Paeds  much less common, and most a/w AVM AVM Adult 10% Tumor, bleeding disorders, blood dyscrasia 5% Idiopathic 15%

Presenting features Sudden onset of a severe headache not previously experienced by the patient. Deterioration of conscious state Meningism Focal neurological signs Intracerebral haemorrhage, local pressure effects, cerebral vasospasm

Grades Hunt and Hess grading system 1 - 5 WFNS grading system 1 -5

Investigations CT Best initial investigations LP, Xanthochromia Confirm the dx in 85% Provide A/W pathology LP, Xanthochromia Correct handling Cerebral Angiography, CTA, DSA

Cerebral Aneurysm Most common cause of SAH in adult Max in 4th and 5th decades of life Arises at the branch points of two vessels 85% anterior half of the circle of Willis 15% posterior half of the circle of Willis Multiple aneurysm occur in 15% of cases

Pathogenesis Saccular, berry or congenital aneurysm Fusiform aneurysm Arises at the junction of vessels Congenital deficiency in the muscle coat Discontinuity of the underlying internal elastic membrane Fusiform aneurysm HTN

Aneurysm (Related facts) Seven fold in first degree relatives 2-5% results in SAH (Lifetime) Hereditary syndromes Ehlers-Danlos Syndrome Coarctation of the Aorta Polycystic kidney disease

Management of ruptured cerebral aneurysm Three factors Severity of the initial haemorrhage 30% cases  death or deeply comatosed Rebleeding of the aneurysm Occurs in about 50% of patients within 6 weeks 25% of patients within 2weeks of the initial haemorrhage. Half of the patients die Prevention VS Risks Cerebral Vasospasm

Cerebral vasospasm Angiographic vasospasm occurs in about 50% of patients following SAH 25% with serious outcome Direct correlation between the amount of blood noted in the basal cisterns. Does not usually occur until 2-3 days after the initial bleed. And rarely delayed after 14days Mx  Hypertensive, Hypervolaemia, Ca antagonist

Mx of Aneurysm Surgery Endovascular obliteration of the aneurysm Occlusion of the neck Reinforcement of the sac Proximal ligation Endovascular obliteration of the aneurysm The access Configuration

AVM Most common cause of SAH in children Haemorrhage Epilepsy Progressive neurological deficit Surgery Size Radiosurgical techniques Less than 3cm