Subarachnoid Hemorrhage

Question 1

Mean age for subarachnoid hemorrhage

Answer 1

50 years of age

Question 2

“Worst headache of my life”

Answer 2

Buzzword for the pain of subarachnoid hemorrhage

Question 3

When do subarachnoid hemorrhages tend to occur?

Answer 3

During physical or emotional strain

For example: In head trauma, during coitus, while defecating

Question 4

Neurogenic pulmonary edema

Answer 4

Complication of subarachnoid hemorrhage

Question 5

___ is frequently seen on chemistries in subarachnoid hemorrhage

Answer 5

Hyponatremia is frequently seen on chemistries in subarachnoid hemorrhage

This correlates with ANP elevation and/or SIADH

Question 6

ECG changes in subarachnoid hemorrhage

Answer 6

QT prolongation and T wave inversion may be seen

Question 7

Sentinel bleed

Answer 7

More mild “warning” headaches that precede a subarachnoid hemorrhage due to aneurysm rupture

Question 8

Vasospasm in the setting of subarachnoid hemorrhage

Answer 8

• Complication that occurs mostly in aneurysm-related SAH
• Incidence peaks 4-14 days following SAH
• Irritation causes vasoconstriction of major cerebral arteries, resulting in lethargy and delayed cerebral infarction
• Dx: Transcranial doppler to detect change in flow velocity in an affected MCA

Question 9

Acute communicating hydrocephalus

Answer 9

• Complication of SAH
• Occurs due to obstruction of the subarachnoid granulations in the venous sinuses by subarachnoid blood
• Presents with headache, vomiting, blurry and double-vision, somnolence, syncope
• CT shows enlarged lateral, third, and fourth ventricles

Question 10

1 cause of nontraumatic subarachnoid hemorrhage

Answer 10

Ruptured saccular/berry aneurysm of the anterior communicating artery

In addition to being the most common, also portends the worst prognosis

Question 11

Diseases that may present with cerebral aneurysm in a relatively young patient

Answer 11

Fibromuscular dysplasia (25%)

Polycystic kidney disease (3%)

Question 12

Diagnostic workup for suspected SAH

Answer 12

1. Noncontrast CT
2. If negative, lumbar puncture (looking for xanthochromia and increased red cells)

Question 13

Prognosis of SAH

Answer 13

Very poor. 60% of patients die within 30 days.

However, level of arousal and symptoms can portend more or less favorable prognoses.

Question 14

Grading of SAH

Answer 14

• Grade I: Alert, mild headache and nuchal rigidity. ~5% risk of moratlity.
• Grade II: Alert, moderate-to-severe headache. ~10% risk of morality.
• Grade III: Drowsy, confused, moderate-to-severe headache, mild focal deficit.
• Grade IV: Stupor. Moderate to severe hemiparesis.
• Grade V: Comatose. Signs of severely increased ICP. High risk for delayed vasospasm. 80% mortality.

Question 15

Treatment of SAH

Answer 15

• Grade I and II may be observed if stable.
• Emergent conventional angiography and neurosurgical intervention is warranted if ruptured aneurysm is suspected.
  
  • Endovascular coiling can reduce rebleeding in low-grade cases
  • Clipping should be performed in first 48 hours after onset OR delayed for 2 weeks in order to avoid the window of high risk for vasospasm.
• Nimodipine may be administered to reduce vasospasm.
• Management of associated conditions (SIADH, neurogenic pulmonary edema, arrhythmias, seizures, hydrocephalus)
  
  • Ventriculostomy may be required for hydrocephalus

Question 16

Anterior communicating aryery aneurysm vs posterior communicating artery aneurysm

Answer 16

• Anterior: Headache, reduced visual acuity, diplopia or bitemporal hemianopsia
• Posterior: Ipsilateral ptosis, pupil dilation, ophthalmoplegia due to compression of CNIII