1. Management of Subarachnoid Hemorrhage Gregory W Balturshot, M.D. Central Ohio Neurological Surgeons May 24, 2013

2. Introduction Risk factors - hypertension, smoking, cocaine, female gender, age >50 Genetic risk factors - Moya Moya, Ehlers-Danlos, PCKD, Marfan’s, fibrimuscular dysplasia

3. Clinical Presentation 80% describe the sudden onset of worst headache on my life 20% experience ‘sentinal headache’ 2-8 weeks before SAH other symptoms include photophobia, nausea and vomiting, seizures, loss of consciousness

4. Hunt Hess Scale

5. Fisher Grade

6. Diagnosis Noncontrast CT - sensitivity 92-95% Lumbar Puncture - Xanthrochromia may take 12 hrs to appear after initial SAH. differentiates from a ‘traumatic tap’ MRI/MRA - sensitivity 55-93% for aneurysms >5mm it is 85-100% CTA - 77-100% and 85-100%. Additional information such as wall calcification, intraluminal thrombus, relationship to the clinoids

7. Gold standard is angiogram

8. Initial Critical Care Management Stablization of systemic oxygenation/hemodynamics ICP control BP control Seizure prophylaxis Prevention of aneurysm rebleeding (9- 17% within 72hrs)

11. Clip vs Coil ISAT - International subarachnoid aneurysm trial 2134 good grade patients with <10 mm aneurysms in the anterior circulation were randomized to clipping or coiling. Death and dependency @ 1 yr 23.5% vs 30.9% Rebleeding rates?

12. Clip vs Coil TEAM approach Factors include the clinical state of the patient, anatomic location, neck to dome ratio (wide neck), hematoma with mass effect