CLINICAL AND NEUROIMAGING STUDIES IN CASES OF SPONTANEOUS SUBARACHNOID HAEMORRHAGE

INTRODUCTION

Subarachnoid haemorrhage (SAH), mostly from aneurysms account for about 4.5 – 13% of all strokes. The incidence of SAH has remained stable over the last 30 years. The reported incidence of SAH in the US, Finland & Japan is high, while it is low in New Zealand and Middle East. INTRODUCTION   

n/100,000 patients 95% CIIncidence 22.0Finland 12.0USA 23.0Japan 14.3New Zealand 26.4 ‡ Australia 7.8Netherlands 8.0Iceland 9.3Greenland Eskimo 3.1Denmark 7.4Faeroe Islands 4.3Indians 5.1Qatar 10.5Overall ‡ Not adjusted for sex & age to the same reference population INTRODUCTION

Aetiology: Ruptured intracranial aneurysms. (Commonest) Cerebral AVMs. CNS vasculitis. Cerebral artery dissection Rupture small superficial artery Rupture of an infundibulum Coagulation disorders.        INTRODUCTION

Dural sinus thrombosis &/or AV fistula. Spinal AVMs Pretruncal non-aneurysmal SAH Rarities: - Tumours - Sickle cell disease - Cocaine abuse - Atrial myxoma - Pituitary apoplexy No cause in 7 – 10%      INTRODUCTION Aetiology:

Risk factors: Unruptured aneurysms Hypertension SmokingRace Age Gender Alcohol consumptionADPCK Connective tissue disorders          INTRODUCTION

Clinical presentation Meningismus 64% Coma 52% Nausea & vomiting 45% No localization sign 39% Global headache 32% Occipital headache 21%       INTRODUCTION

Clinical presentation Motor deficit 17% Dysphasia 13% Confusion 12% Intraocular haemorrhages 12% Anisocoria 12%      INTRODUCTION Reflex changes 19% 

Clinical presentation Lateralized headache 8% Third nerve palsy 7% Sensory disturbance 5%    INTRODUCTION Papilloedema 11% Homonymous hemianopsia 9%  

Complications Ischaemic deficits 27% Hydrocephalus 12% Brain swelling 12% Recurrent haemorrhage 11% Intracranial hematoma 8% Pneumonia 8%       INTRODUCTION

Gastrointestinal haemorrhage 4% SIADH 4% Pulmonary oedema 1% Seizures 5%     INTRODUCTION Complications

Investigations Computed Tomography (CT) Hydrocephalus 20% The presence of intraventricular blood (13-28%) Intraparenchymal blood (20-40%) Subdural blood (1 - 3%)     INTRODUCTION

Investigations Computed Tomography (CT) The pattern of SAH Blood in cistern and fissures With presence of multiple aneurysms it detect which one bled   

INTRODUCTION Investigations Lumbar puncture (LP): Elevated opening pressure Xanthochromia Elevated proteins RBCs > cm 3    

INTRODUCTION Investigations CT angiography (CTA): Suspicion of an aneurysm on conventional CT Follow up of previously diagnosed aneurysm not planned for surgery Follow up of aneurysm anatomy after surgery Detection of ruptured aneurysms     Screening 

INTRODUCTION Investigations MRI: A unique method for identifying aneurysm in patient who not reffered till after 5 – 10 days, and brain CT showed no subarachnoid blood. FLAIR MRI is more sensitive than CT in detection of acute SAH.  

INTRODUCTION Investigations MRA: For detecting aneurysm with sensitivity 85% and specificity around 90%. For vasospasm identification the sensitivity is 92% and specificity 97%.  

INTRODUCTION Investigations TCD: Highly specific 100%, but relatively insensitive in detecting vasospasm. Assess the intraaneurysmal dynamics.  

INTRODUCTION Investigations Cerebral angiography: The gold standard for the diagnosis of the intracranial aneurysm. Negative in 20%.  

INTRODUCTION Investigations Cerebral angiography: Complications:  - Hypersensitivity to contrast agent. - TIA - TGA - Death 1/20 –

Management General - Nursing - Nutrition - Blood pressure- Fluid and electrolytes - Pain - Prevention of DVT, or pulmonary embolism INTRODUCTION

Vasospasm Prophylactic treatment: - CCB (Nimodipine)- Olprinone - Tirilazed - Other investigational drugs (FK 506, TBC , L-Argininive monoclonal antibodies. Defferoxamine and prostacyclines, AVS, CGU.  INTRODUCTION Management

- Intrathecal sodium nitroprusside - Nitroglycerine - Cyclosporin - Steroids INTRODUCTION Vasospasm Curative treatment:  Management - Hyperdynamic Therapy (Triple H therapy)

- Barbiturate coma - Cisternal irrigation - Gene therapy - Angioplasty - Intra-arterial injection of vasodilator - Intra-aortic counterpulsation INTRODUCTION Vasospasm Curative treatment:  Management

Antifibrinolytic drugs (TEA, EACA) Early surgical intervention   INTRODUCTION Management Rebleeding

Conservative Repeated LP Vetriculostomy Shunt     INTRODUCTION Management Hydrocephalus

Hyponatraemia Cardiac complications Pulmonary complications    INTRODUCTION Management Systemic complication

Trapping Proximal ligation (hunterian ligation) Thrombosing aneurysm with GDC & Balloon embolization.    INTRODUCTION Management Endovascular & nonsurgical techniques to treat the aneurysm

Clipping Wrapping Coating    INTRODUCTION Management Surgical treatment

AIM OF THE WORK

This work is carried out to evaluate the clinical presentation and various diagnostic procedures of spontaneous subarachnoid haemorrhage. AIM OF THE WORK

PATIENTS & METHODS

PATIENTS & METHODS

PATIENTS WERE SUBJECTED TO History taking Laboratory investigations Neurological examination Lumbar puncture CT scanning & CTA MRI FLAIR MRA 4 vessels angiography

Table : Hunt and Hess scale DescriptionGrade Asymptomatic or mild headache and slight nuchal rigidityI Cr. N. palsy, moderate to severe headache, nuchal rigidityII Mild focal deficit, lethargy, or confusionIII Stupor, moderate to severe hemiparesis, early decerebrate rigidityIV Deep coma, decerebrate rigidity, moribund appearanceV Modified classification adds the following: Unruptured aneurysm0 No acute meningeal/brain reaction, but with fixed neuro deficitIa Add one grade for serious systemic disease (eg HTN, DM, COPD, or atherosclerosis) or severe vasospasm on arteriography PATIENTS & METHODS

RESULTS

SAH Number and percentage of stroke patients admitted to the neurology department in Mansoura Emergency University Hospital in the period of the study Haemorrhagic stroke Ischemic stroke RESULTS

Male Sex distribution Female RESULTS

> 70 Age distribution in males RESULTS

> 70 Age distribution in females RESULTS

Sex distribution in the different grade of the studied patients RESULTS

Clinical Grading System according to H & H. RESULTS

Mean age in the different grade of the studied patients RESULTS

6 PM : 12 AM percentage of patients according to time of onset of SAH 12 AM : 6 AM 6 AM : 12 PM 12 PM : 6 PM RESULTS

Incidence of SAH in the 24 hours SAH RESULTS

Frequency of risk factors RESULTS

30 days case fatality rate RESULTS

The relation between the clinical grades and mortality rate RESULTS

Causes of short term mortality RESULTS

CT finding in our series RESULTS

MRA finding of the examined patients RESULTS

Conventional angiography finding in our series RESULTS

CASE 1

CASE 2

CASE 3

CASE 4

CONCLUSIONS

Sudden, explosive headache is a cardinal but nonspecific feature in the diagnosis of SAH : in general practice, the cause is innocuous in nine out of the ten patients in whom this is the only symptom The incidence of subarachnoid haemorrhage is 3.8% of all strokes in our locality,and presenting 12.4% of the haemorrhagic strokes. CONCLUSIONS

48% of patients presented by sudden, severe headache, nuchal rigidity and cranial nerve palsy, while 24% presented by stuporous consciosness and severe hemiplegia, and only 6 % with deep coma. Most patients are below sixty years of age, and women are more suffered. Risk factors are the same as for stroke in general ; genetic factors operate in only a minority. CONCLUSIONS

30 day case-fatility is 46%, the majority of them in the first week after admission due to rebleeding and the effect of this initial haemorrhage. Hypertension, smoking, diabetes, age and dyslipedemia are the main risk factors. CONCLUSIONS

MRI FLAIR is superior than CT in detecting SAH in subacute phase where the patient come after the onset by one or two weeks. Four-Vessels angiography more sensitive in detecting intracranial aneurysms in comparison to MRA. CT scanning is mandatory in all, to be followed by (delayed ) lumber puncture if CT is negative. CONCLUSIONS

RECOMMENDATIONS

The Clinician should have a high index of suspicion that a sudden, severe, unexplained headache in any patients could represent an acute subarachnoid haemorrhage. If the CT scan is positive, lumber puncture is unnecessary and dangerous due to risks of aneurysm rebleeding or transetentorial brain herniation. RECOMMENDATIONS

Once the diagnosis is confirmed with a CT scan, a neurosurgeon who can ultimately treat the patient should be contacted immediately. Delay in transfer may prove fatal because of potential for aneurysm rebleeding prior to intervention RECOMMENDATIONS If the CT scan is negative, lumber puncture may be helpful if the history of ictal headache is not typical of subarachnoid haemorrhage

RECOMMENDATIONS Blood pressure must closely monitored and controlled following SAH. Hypertension will increase the chance of catastrophic rebleeding. Blood pressure control should be initiated immediately upon diagnosis of SAH.

RECOMMENDATIONS Preoperative medications include prophylactic anticonvulsants, and antihypertensives as needed. Not initiate antifibrinolytic therapy unless surgery is not considered within 48 hours of initial SAH.

RECOMMENDATIONS All X-rays, MRI scans, and lab work sent with the patients to avoid needless repetition. Surgery or endovascular coiling to obliterate the ruptured aneurysm should performed as soon as possible after the onset of SAH. Poor grade patients, grades 4 and 5, are treated non- operatively or neurointerventionally until their clinical condition improves.

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