1. Subarachnoid Heamorrhage SAH
AHA & Piotr Szczudlik MD

5. Nonaneurysmal causes of SAH 25%
Trauma
Arteriovenous malformation
Intracranial arterial dissection
Cocaine and amphetamine use
Mycotic aneurysm (septic)
Central nervous system vasculitis
Coagulation disorders

7. Risk factors Hypertension OR-2,6 Smoking OR-2,2
High alcohol intake OR-1,5
First degree relatives
Ehlers-Danlos, Marfan’s syndrome, pseudoxantoma elasticum, neurofibromatosis t. 1, polycystic kidney disease

11. 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

14. SAH is preceded in about 10% of the cases by a “sentinel headache”or warning leak, an episode of headache similar to that of SAH,and preceding it by days or weeks.

15. Misdiagnosis
20 % !!!

18. Perimesencephalic pattern of SAH
venous origin or due to intramural dissection
benign course
it can be complicated by hydrocephalus

22. !!!! In 20-25% patients in acute stage the sight of bleeding will not be find in clasical arteriography (due to vasospasm, slot in aneurysm, and misinterpretation)

27. Management protocol for acute SAH
Control elevated blood pressure to prevent rebleeding
Intravenous hydration
Check complete blood cell count, electrolytes (hyponatremia), CK-MB
Vasospasm prophylaxis (nimodipine 60 mg p.o. every 4 hrs for 21 days)

28. Triple H therapy
Hypertension 160mmHg
Haemodilution
Hypervolaemia

30. Recurrent Hemorrhage If the aneurysm is not treated, the risk
of rebleeding within 4 weeks is estimated to be of 35–40%
After the first month the risk decreases
gradually from 1–2%/day to 3%/year

35. surgery vs endovascular
< 60
MCA
wide neck of aneyrysm
large ICH
old age
bad condition
aneurysm in posterior localization (basilar artery)

43. Asympyomatic Aneurysms
Contrary to current beliefs, aneurysms are not congenital but develop continuously during lifetime.
Unruptured aneurysms have a risk of rupture of ~1%/year, depending on their size.
Current evidence indicates that in patients with a life expectancy of at least 20 years, only those in the anterior circulation < 7mm should be left untreated.
Screening for unruptured aneurysms is controversial.