1. Subarachnoid Haemmorhage
By Fiona Hill
HMO3 Surgical

2. Introduction Average case fatality rate for SAH: 51% Of these, approx:
20% of strokes are hemorrhagic:
- half SAH
- half ICH
Average case fatality rate for SAH: 51%
Of these, approx:
10% of patients die prior to reaching the hospital
25% die within 24 hours
45% die within 30 days
More than one third of survivors have major neurologic deficits

3. Anatomy

4. SAH: Overview
Subarachnoid hemorrhage implies blood within the subarachnoid space from some pathologic process.
Most SAHs are caused by ruptured saccular aneurysms ~ 77%
Dilatations of a vascular lumen caused by wall weakness
Commonly in the Circle of Willis
Other causes include: trauma, AVM, vasculitides, intracranial arterial dissections, amyloid angiopathy, and illicit drug use.
1-5 percent of people have aneurysms.
Of these % have multiple
Aneurysmal SAH occurs at an estimated rate of 3 to 25 per 100,000 population.
Mean age at onset: 55 years (40 and 60 years of age)
(especially cocaine and amphetamines).
The prevalence of intracranial saccular aneurysms by radiographic and autopsy series is or 10 to 15 million people in the United States.

5. History Sudden onset of a severe headache.
Prodromal headache from minor blood leakage (sentinel headache) is reported in 30-50% of aneurysmal SAH.
Symptoms of meningeal irritation - 75% of cases.
Nausea and/or vomiting.
Photophobia and visual changes.
> 25% of patients experience seizures close to onset.
Loss of consciousness: 50% of patients at time of bleed.

6. Physical Examination Vital signs
50% have mild-to-moderate blood pressure (BP) elevation.
Global or focal neurologic abnormalities in more than 25% of patients
Syndromes of cranial nerve compression
Motor deficits from middle cerebral artery aneurysms in 15% of patients
Seizures
Ophthalmologic signs: eg Papilledema, haemorrhages

7. Location of aneurysms
85% of saccular aneurysms occur in the anterior circulation.
Most common sites of rupture :
Internal carotid artery, including the posterior communicating junction (41%)
The anterior communicating artery/anterior cerebral artery (34%)
The middle cerebral artery (20%)
The vertebral-basilar arteries (4%)
Other arteries (1%)
(especially cocaine and amphetamines).
The prevalence of intracranial saccular aneurysms by radiographic and autopsy series is or 10 to 15 million people in the United States.

8. Risk Factors x Cigarette smoking Hypertension
Excessive Alcohol Consumption
Genetic risk 
Sympathomimetic drugs

9. Grading scales Hunt and Hess grading system
Grade 1 - Asymptomatic or mild headache
Grade 2 - Moderate-to-severe headache, nuchal rigidity, and no minimal neurological deficit.
Grade 3 - Mild alteration in mental status (confusion, lethargy), mild focal neurological deficit
Grade 4 - Stupor and/or hemiparesis
Grade 5 - Comatose and/or decerebrate rigidity
WFNS scale
Grade 1 - Glasgow Coma Score (GCS) of 15, motor deficit absent
Grade 2 - GCS of 13-14, motor deficit absent
Grade 3 - GCS of 13-14, motor deficit present
Grade 4 - GCS of 7-12, motor deficit absent or present
Grade 5 - GCS of 3-6, motor deficit absent or present
Fischer scale (CT scan appearance)
Group 1 - No blood detected
Group 2 - Diffuse deposition of subarachnoid blood, no clots, and no layers of blood greater 1 mm
Group 3 - Localized clots and/or vertical layers of blood 1 mm or greater in thickness
Group 4 - Diffuse or no subarachnoid blood, but intracerebral or intraventricular clots are present

10. Imaging First line: CT scan without contrast
Sensitivity decreases with time from onset and with older resolution scanners.
Cerebral angiography is performed once the subarachnoid hemorrhage diagnosis is made.
This study assesses the following: vascular anatomy, current bleeding site, and presence of other aneurysms.
This study helps plan operative options.
Angiography findings are negative in 10-20% of patients with subarachnoid hemorrhage.
MRI/MRA is performed if no lesion is found on angiography.

11. Lumbar puncture
Indicated if the patient has possible subarachnoid haemorrhage and negative CT scan findings.
Perform CT scan prior to LP to exclude any significant intracranial mass effect or obvious intracranial bleed.
Timing:
LP may be negative less than 2 hours after the bleed; LP is most sensitive at 12 hours after symptom onset.
Findings:
RBC remain consistently elevated in 2 sequential tubes.
Xanthochromia usually is seen by 12 hours after the onset of bleeding,
LP findings were thought to be positive in 5-15% of all subarachnoid hemorrhage presentations that are not evident on the CT scan.

12. Case: Mrs Agnes
A 51 y/o Lebanese lady comes in with her husband complaining of a vague headache lasting two days which this morning acutely progressed into a severe occipital headache.

13. Case: Mrs Agnes PCx: Has had a vague 2/10 headache for 48/24.
Acutely developed severe headache this am.
10/10
Associated symptoms of photophobia, neck pain, nausea.
PMHx:
TIIDM – insulin dependant
Hypertension
Hypercholesterolaemia
GORD
Meds: Insulin, frusemide, OCP, lansoprazole
NKDA
Social Hx:
Housewife, lives with husband + two children.
Current smoker, 30+ pack years.
Alcohol: nil Other substances: nil

14. Case: Mrs Agnes Examination: GCS: 14/15 E3V5M6 Vitals:
Pt drowsy, photophobic to lights in room.
GCS: 14/15 E3V5M6
Vitals:
- TEMP BP 200/90mmHg - PR 94bpm RR 15 Sat 100% 2L.
Neuro:
PEARL, FROEM,
CN II-XII – unremarkable.
UL + LL – normal tone, power 5/5, reflexes normal, sensate throughout.
CVS, Resp, Abdo examination unremarkable.

15. First Line Investigations
Bloods:
FBC, U&E, Coags, Troponin, G&H
Imaging:
CTA

19. Case: Diagnosis Acomm aneurysm SAH secondary to Acomm A WFNS Grade II
Fisher III
SAH secondary to Acomm A
GA/Supine.
Right Kocher’s point identified
Shave prep G.A.
Linear incision
Burr hole
EVD inserted – confirmed high pressure.
EVD secured and connected to extenral drainage bag.

20. Case: Mrs Agnes Over next 1/24 - progressively more drowsy
What are you concerned about?
Raised intracranial pressure
What would you do about it?
EVD inserted
What’s the next step?
Angiogram +/- coiling
GA/Supine.
Right Kocher’s point identified
Shave prep G.A.
Linear incision
Burr hole
EVD inserted – confirmed high pressure.
EVD secured and connected to extenral drainage bag.

23. Case: Management Whats next?
Emergengy theatre when available to clip aneurysm.
Interim:
IV nimodipine + PRN hydralazine
Load Phenytoin
SBP strickly <140mmHG for unsecured aneurysm.
QIH neuro obs,
Head up at degress.
FFMN
CVC
Notify if GCS drops >2, unreactive pupils or 2mm or more in difference
GA/Supine.
Right Kocher’s point identified
Shave prep G.A.
Linear incision
Burr hole
EVD inserted – confirmed high pressure.
EVD secured and connected to extenral drainage bag.

24. Case: Mrs Agnes
New R facial droop, desaturation and decreased FCS post ACA. Urgent CT B _ DSA: no vasospasm.
Left frontal craniotomy + Acom clip noted.
Small mised attenuated extraaxial collection seen deep to surgical site meatureing maximal depth
DSA: no ecidence of vasospasm or arterial occlusion. The ACOM aneurysm is exclused from cirulcatin with a residual neck of 2mm.

25. Thank you!