Subarachnoid Haemorrhage

Question 1

What is the major cause of a subarachnoid haemorrhage?

Answer 1

Rupture of saccular aneurysms 80%

Question 2

What is a less common cause of subarachnoid haemorrhage?

Answer 2

rupture of arteriovenous malformations 15%

Question 3

When does subarachnoid haemorrhage display gender preference?

Answer 3

Only slight female preference (3:2) >45 years

Could indicate women more susceptible post-menopause

Question 4

Where are saccular aneurysms most common?

Answer 4

Junction of the posterior communicating with internl carotid

Anterior communicating with anterior cerebral artery of bifurcation of the MCA

Question 5

Where are saccular aneurysms most common?

Answer 5

Junction of the posterior communicating with internl carotid

Anterior communicating with anterior cerebral artery of bifurcation of the MCA

Question 6

What percentage of subarachnoid haemorrhage cases have multiple aneurysms?

Answer 6

~15%

Question 7

What other conditions are subarachnoid haemorrhages associated with?

Answer 7

Polycystic kidney

Coarctation of the aorta

Ehlers-Danlos syndrome

Question 8

What is the classic symptom that is a red flag for subarachnoid haemorrhage?

Answer 8

Development of an instantaneous, devastating headache without warning

Question 9

What symptoms typically follow the initial headache of subarachnoid haemorrhage?

Answer 9

Vomiting

Collapse

Seizures

Coma

Question 10

What signs can be found in subarachnoid haemorrhage?

Answer 10

Neck stiffness/Kernig’s sign

CN palsies

Question 11

What percentage of patients presenting with a ‘thunderclap’ headache have subarachnoid haemorrhage?

Answer 11

25%

Most are idiopathic, rest are meningitis, migraine, intracerebral bleeds, cortical vein thrombosis

Question 12

Why should we be particularly concerned about any sudden headache?

Answer 12

Because aneurysms can have warning leaks

The least symptomatic subarachnoid haemorrhages are the most successful in terms of surgical intervention, hence we should always be on the lookout

Question 13

What is the investigation of choice in subarachnoid haemorrhage?

Answer 13

CT

Detects >90% of SAH within the first 48 hours

Question 14

When should you do an LP in subarachnoid haemorrhage, and what will it show?

Answer 14

If CT is -ve despite strong clinical suspicion, and no contraindications to the LP

Should be done at least 12 hours after the onset of symptoms though

Question 15

Why should we be particularly concerned about any sudden headache?

Answer 15

Because aneurysms can have warning leaks (sentinel headaches)

The least symptomatic subarachnoid haemorrhages are the most successful in terms of surgical intervention, hence we should always be on the lookout

Question 16

When should you do an LP in subarachnoid haemorrhage?

Answer 16

If CT is -ve despite strong clinical suspicion, and no contraindications to the LP

Should be done at least 12 hours after the onset of symptoms though

Question 17

What will you find in CSF in subarachnoid haemorrhage?

Answer 17

Uniformly bloody early on

Becomes xanthomorphic (yellow) later on due to breakdown products of Hb (bilirubin)

Question 18

Would a uniformly bloody LP or a xanthomorphic LP be more indicative of a subarachnoid haemorrhage?

Answer 18

Xanthomorphic

Blood in the CSF could be from the LP procedure itself, where bilirubin in CSF could not

Question 19

Why should we be particularly concerned about any sudden headache (especially with neck and/or back pain)?

Answer 19

Because aneurysms can have warning leaks (sentinel headaches)

The least symptomatic subarachnoid haemorrhages are the most successful in terms of surgical intervention, hence we should always be on the lookout

Question 20

Would a uniformly bloody LP or a xanthomorphic LP be more indicative of a subarachnoid haemorrhage?

Answer 20

Xanthomorphic

Blood in the CSF could be from the LP procedure itself, where bilirubin in CSF could not

Question 21

Would a uniformly bloody LP or a xanthomorphic LP be more indicative of a subarachnoid haemorrhage?

Answer 21

Xanthomorphic

Blood in the CSF could be from the LP procedure itself, where bilirubin in CSF could not

Question 22

Should HTN be managed in the acute subarachnoid haemorrhage setting?

Answer 22

No

High BP increases cerebral perfusion

Question 23

What blood pressure should be aimed for in the setting of subarachnoid haemorrhage?

Answer 23

> 160mmHg

Question 24

What drug is useful in the setting of subarachnoid haemorrhage for controlling vasospasm?

Answer 24

Nimodipine

Question 25

Is endovascular coiling or surgical clipping more effective in the treatment of subarachnoid haemorrhage?

Answer 25

Endovascular clipping

Question 26

What is the trade-off when it comes to endovascular clipping in the setting of subarachnoid haemorrhage?

Answer 26

Increased chance of rebleeding (despite increased chance of survival)

Question 27

Should surgical intervention be done before angiography in the setting of subarachnoid haemorrhage?

Answer 27

No

CT/catheter angiography should be performed first, to determine whether there are single or multiple aneurysms that require management

Question 28

What are some common complications of subarachnoid haemorrhage?

Answer 28

Rebleeding

Cerebral ischaemia due to vasospasm (treat with nimodipine)

Hydrocephalus due to blockage of aranchoid granulations, requires a ventricular or lumbar drain

Question 29

What are some poor prognostic markers for subarachnoid haemorrhage?

Answer 29

Drowsiness (37% mortality)

Hemiplegia (71% mortality)

Coma (100% mortality)

Question 30

What are some poor prognostic markers for subarachnoid haemorrhage?

Answer 30

Drowsiness (37% mortality)

Hemiplegia (71% mortality)

Coma (100% mortality)

Question 31

What agent is nimodipine?

Answer 31

Dihydropiridine calcium channel blocker