1. Nina T. Gentile, MD Associate Professor Department of Emergency Medicine Temple University Hospital & School of Medicine Philadelphia, PA Nina T. Gentile, MD, FAAEM

2. Subarachnoid Hemorrhage

3. Nina T. Gentile, MD, FAAEM

4. American Stroke Association Ad Council

5. Nina T. Gentile, MD, FAAEM Vertebral artery angiogram. Arrows show aneurysmal dilatation of intracranial portion of the vertebral artery. Frontal Lateral

6. Nina T. Gentile, MD, FAAEM Spontaneous SAH Rupture arterial aneurysm Rupture AVM Perimesenchymal vein or capillary bleeding 95%

7. Nina T. Gentile, MD, FAAEM Saccular AVM Arteriosclerotic Mycotic Traumatic Dissecting Neoplastic Drugs Sahs et al

8. Nina T. Gentile, MD, FAAEM MCA 25% Ant CoA 25% Post CoA 25% ACA 5% PCA 2% VBA 13%

9. Nina T. Gentile, MD, FAAEM Clinical Manifestations Ruptured aneurysm headache stiff neck focal deficit Ribeiro JA., et al, Acta Medica Portuguesa. 11(12):1085-90, 1998 Dec.

10. Nina T. Gentile, MD, FAAEM Confusion/Lethargy Decreased alertness, Confusion, or Irritability Temporary Persistent Progressively worse to coma and death Syncope Mental Status Exam Six-Item Screen

11. Nina T. Gentile, MD, FAAEM SAH: Signs Abnormal vital signs Respiratory variation Hypertension Irregular heart rate

12. Nina T. Gentile, MD, FAAEM SAH: Signs Focal neurologic signs III nerve palsy – IC/PCA aneurysm Hemiparesis, aphasia – MCA aneurysm Paraparesis – ACA aneurysm

13. Nina T. Gentile, MD, FAAEM Warning or “Sentinel” Bleeds Up to 50% of patients with SAH report a distinct, severe headache in the days or weeks before the index bleed Milder sxs H/o Headaches J Neurosurgery 1987

14. Nina T. Gentile, MD, FAAEM Outcome Missed (n=45) Correct Dx (n=75) Excellent/good 24 (53)* 68 (91)* Fair 5 (11) 4 (5) Poor (vegetative/dead) 16 (36)* 3 (4)* Values are number (%)*P<.001 Outcome of Patients Misdiagnosed and Correctly Diagnosed With SAH

15. Nina T. Gentile, MD, FAAEM Features of Disdiagnosed Patients JAMA. 2004;291:866-8

16. Nina T. Gentile, MD, FAAEM Features of Disdiagnosed Patients JAMA. 2004;291:866-8

17. Nina T. Gentile, MD, FAAEM Features of Disdiagnosed Patients JAMA. 2004;291:866-8

18. Nina T. Gentile, MD, FAAEM Who Needs Imaging? Sudden acute-onset headache Prospective studies report that 30% of patients complaining of the “worst headache of their life” had positive findings on CT.

19. Nina T. Gentile, MD, FAAEM Who Needs Imaging? Occipital location Worsens with Valsalva Awakens from sleep Associated with syncope, nausea, or sensory distortion.

20. Nina T. Gentile, MD, FAAEM Computed Tomography Sensitive for blood day of the bleed  95% within 12 hours of symptom onset  as high as 98%. Sensitivity drops when symptoms are days in duration amount of bleeding is small  85% study is difficult to interpret

21. Nina T. Gentile, MD, FAAEM

22. Ruptured Ant CoA aneurysm 

23. Nina T. Gentile, MD, FAAEM SAH 2 0 ruptured right PCA

24. Nina T. Gentile, MD, FAAEM Normal Circle of Willis 3-D CT-A

25. Nina T. Gentile, MD, FAAEM Normal Circle of Willis 3-D CT-A

26. Nina T. Gentile, MD, FAAEM SAH 2 0 ruptured ACA aneurysm 3-D CT-A

27. Nina T. Gentile, MD, FAAEM SAH 2 0 ruptured PCoA aneurysm 3-D CT-A

28. Nina T. Gentile, MD, FAAEM Lumbar puncture and CSF Exam LP whenever the CT or CTA is negative, equivocal, or technically inadequate Blood or red blood cells in the first 8 hrs. Xanthochromia or an inflammatory reaction when CSF exam delayed

29. Nina T. Gentile, MD, FAAEM Lumbar Puncture

30. Nina T. Gentile, MD, FAAEM SAH: Complications Multisystem Failure Increased Intracranial Pressure Rebleeding Vasospam

31. Nina T. Gentile, MD, FAAEM Anemia Venous thrombosis Bleeding disorder  Na+ /  Na+ Water loss Hypokalemia  BP /  BP MI/Ischemia Arrhythmias Heart failure ARDS Pneumonia Atelectasis Multisystem Complications

32. Nina T. Gentile, MD, FAAEM Increased Intracranial Pressure ICP monitoring Raising head Hypocarbia Steroids? Fluid restriction? Hypothermia Mannitol Barbiturate coma? Ventriculostomy Major Cause of Death

33. Nina T. Gentile, MD, FAAEM SAH: Complications VASOSPASMREBLEEDING Kassell et al 0 0 1 2 3 4 5 PERCENT PROBABILITY 1234567891011121314 DAYS AFTER INITIAL SAH

34. Nina T. Gentile, MD, FAAEM Rebleeding Leading cause of death or morbidity during the first 2 weeks after SAH Incidence: 4-10% in 24 hours 15-25% in 2 weeks 2-3% after 1 month for 10 years Presents with sudden change in neurological status, new headache and coma.

35. Nina T. Gentile, MD, FAAEM Treatment: Prevent Rebleeding Aneurysmal Clipping Endovascular Coiling Hematoma Evacuation Procoagulatants

36. Nina T. Gentile, MD, FAAEM ISAT Study Patients with ruptured intracranial aneurysms Dependency or Death at 1 year Neurosurgical Clipping 243/793 (30.6%) Endovascular Coiling 190/801 (23.7%) Lancet. 2002;360(9342):1267-74

37. Nina T. Gentile, MD, FAAEM Hematoma Evacuation

38. Nina T. Gentile, MD, FAAEM Hematoma Evacuation

39. Nina T. Gentile, MD, FAAEM Potential role of NovoSeven in the prevention of rebleeding following aneurysmal subarachnoid haemorrhage. Prevent Rebleeding Blood Coagul Fibrinolysis. 2000 Apr;11 Suppl 1:S117-20.

40. Nina T. Gentile, MD, FAAEM Normal Caliber Vasospasm SAH: COMPLICATIONS

41. Nina T. Gentile, MD, FAAEM Treatment: Prevent Vasospasm Maintain BP Oral Nimodipine Intraoperative t-PA?

42. Nina T. Gentile, MD, FAAEM Calcium Channel Blockers  BP  Intracellular and transmembrane calcium fluxes Oral Nimodipine is ideal crosses BBB and has limited cardiovascular effects reduces the incidence of cerebral infarction and improves outcome by 40% when administered within 4 hrs of SAH. Cochrane Database Syst Rev. 2000;(2):CD000277

43. Nina T. Gentile, MD, FAAEM Prevent Vasospasm—t-PA? Instill 1-10 mg t-PA into the basal cistern after aneurysm clipping Facilitates earlier ‘clearing’ of blood clots and ventricular drainage Can avert cerebral ischemia after SAH Neurosurgery. 2004 Sep;55(3):532-7 Neurol Neurochir Pol. 2000;34(6 Suppl):41-7

44. Nina T. Gentile, MD, FAAEM Teaching Points SAH is often misdiagnosed CT is sensitive but not fool-proof LP for patients with normal or equivocal CT Early angiography and IR/ Neurosurgery eval to facilitate intervention Treat to prevent multisystem and neurological complications of SAH. Attend to the airway and BP Monitor and Control ICP Prevent Re-bleeding and Vasospasm

45. Nina T. Gentile, MD, FAAEM Copyright © Warner Bros. Pictures Inc.

46. Nina T. Gentile, MD, FAAEM Copyright © Warner Bros. Pictures Inc.

47. Questions?? www.ferne.org ferne@ferne.org Nina Gentile, MD Questions?? www.ferne.org ferne@ferne.org Nina Gentile, MD ngentile@temple.edu 215 707 8402 www.ferne.org Nina T. Gentile, MD, FAAEM