1. Subarachnoid Haemorrhage
Dr. Jonathan Yang
Neurosurgery

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

3. 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%

4. 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

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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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