1. Subarachnoid hemorrhage
Dr. Ari Sami Hussain Nadhim
Consultant Neurosurgeon
Scxhool of Medicine
University of Sulaimani
2013
Dr. Ari Sami Hussain Nadhim

2. Dr. Ari Sami Hussain Nadhim
SAH
Bleeding from intracranial vessels lie in the SA space which give off small perforating branches to the brain tissue or from an associated aneurysm.
Dr. Ari Sami Hussain Nadhim
Dr. Ari Sami Hussain Nadhim

3. Dr. Ari Sami Hussain Nadhim
Incidence
It represents about 5-10% of all non-traumatic ICH with an incidence of approximately 10-15/ population per year
Dr. Ari Sami Hussain Nadhim

4. Dr. Ari Sami Hussain Nadhim
Causes of SAH
Rupture of a berry aneurysm.
Rupture of AVM (6%) (Children)
Rare Causes:
Bleeding from a tumor
Bleeding disorders
Blood dyscrasias
Rupture of spinal AVM
Undiagnosed cause in 15%
Dr. Ari Sami Hussain Nadhim

5. Dr. Ari Sami Hussain Nadhim
Presenting features:
Headache:
Sudden onset of a severe headache of a type not experienced by the patient
Described as a blow to the head
Dr. Ari Sami Hussain Nadhim

6. Dr. Ari Sami Hussain Nadhim
Deteriorated level of consciousness
Meningism
Headache, fever, neck stiffness, photophobia, and vomiting
Dr. Ari Sami Hussain Nadhim

7. Dr. Ari Sami Hussain Nadhim
Focal neurological signs:
Due to:
Concomitant ICH:
MCA (Temporal lobe and Parietal lobe), ACA (Frontal lobe)
Local pressure effect of aneurysm (PCA and 3rd nerve palsy)
Cerebral vasospasm ( 2-3 days after the bleeding)
Dr. Ari Sami Hussain Nadhim

8. Dr. Ari Sami Hussain Nadhim
Epilepsy
Optic fundi: papilloedema
Retinal hemorrhage (subhyaloid)
Reactive hypertension
pyrexia
Dr. Ari Sami Hussain Nadhim

9. Dr. Ari Sami Hussain Nadhim
Diagnosis:
History and examination:
Sudden severe headache
Decrease conscious state
Meningism
Dr. Ari Sami Hussain Nadhim

10. Dr. Ari Sami Hussain Nadhim
CT scan
It will show the hemorrhage in 95% of patients with SAH (if within 48 hours of the bled)
Hydrocephalus
ICH
Aneurysm or AVM
Tumor
Dr. Ari Sami Hussain Nadhim

11. Dr. Ari Sami Hussain Nadhim

12. Dr. Ari Sami Hussain Nadhim
MRI
Not routinely used
Used in spinal AVM which cause SAH
Dr. Ari Sami Hussain Nadhim

13. Dr. Ari Sami Hussain Nadhim
CT/MR angiography
Non-invasive techniques
Will detect up to 95% of intracranial aneurysms
Dr. Ari Sami Hussain Nadhim

14. Dr. Ari Sami Hussain Nadhim

15. Dr. Ari Sami Hussain Nadhim
LP:
Xanthochromia:
Allow CSF to drip into 3 consecutive tubes
Dr. Ari Sami Hussain Nadhim

16. Dr. Ari Sami Hussain Nadhim
Cerebral angiography
Aneurysm
AVM
Vessel spasm
Dr. Ari Sami Hussain Nadhim

17. Dr. Ari Sami Hussain Nadhim

18. Dr. Ari Sami Hussain Nadhim
Aneurysm
The most common cause of SAH with a maximum incidence in the 4th-5th decades of life
The majority of aneurysms occur in constant positions of the circle of Willis and about 85% occur in the anterior half of the circle
Dr. Ari Sami Hussain Nadhim
Dr. Ari Sami Hussain Nadhim

19. Clinical presentation
Rupture
Compression from aneurysm sac
Visual
Cranial nerves
Pituitary
Brainstem
incidental
Dr. Ari Sami Hussain Nadhim

20. Dr. Ari Sami Hussain Nadhim
Management
Severity of initial hemorrhage
Rebleed: 50% within 6 weeks
Antifibrinolytic agents are not used because of thrombotic phenomena (DVT, cerebral thrombosis)
Dr. Ari Sami Hussain Nadhim

21. Dr. Ari Sami Hussain Nadhim
Cerebra vasospasm:
Hypertensive and hypervolemic therapy
Calcium channel blocking agents (Nimodipine)
Dr. Ari Sami Hussain Nadhim

22. Dr. Ari Sami Hussain Nadhim
Surgery:
Occlusion of the neck
Reinforcement of the sac
Proximal ligation of the feeding vessel
Endovascular procedures (detachable coils)
Dr. Ari Sami Hussain Nadhim

23. Dr. Ari Sami Hussain Nadhim
AVM
Most common cause of SAH in children and young patients
Clinical presentation:
Hemorrhage
Epilepsy
Headache
Progressive neurological deficits
Dr. Ari Sami Hussain Nadhim

24. Dr. Ari Sami Hussain Nadhim

25. Dr. Ari Sami Hussain Nadhim
Management
Excision
Stereotactic radiosurgery
Embolisation
Dr. Ari Sami Hussain Nadhim