Subarachnoid haemorrhage

Question 1

Define the term Subarachnoid haemorrhage

Answer 1

Defined as a bleed in the subarachnoid space, space between the arachnoid and pia mater, two meningeal layers

Question 2

Subarachnoid haemorrhage is a bleed in which part of the brain

Answer 2

In the subarachnoid space

Question 3

The subarachnoid space is a space between which two layers of the meninges

Answer 3

arachnoid and pia mater

Question 4

CSF is found between which two meninges

Answer 4

Arachnoid and pia mater - within the subarachnoid space

Question 5

Name the two classifications of a subarachnoid hemorrhage

Answer 5

Traumatic subarachnoid haemorrhage

Spontaneous subarachnoid haemorrhage

Question 6

Define the term Traumatic subarachnoid haemorrhage

Answer 6

Refers to a subarachnoid haemorrhage in the presence of trauma e.g., fall, assault, road traffic collision

Question 7

Define the term Spontaneous subarachnoid haemorrhage

Answer 7

Refers to a subarachnoid haemorrhage in the absence of trauma e.g., ruptured of a cerebral aneurysm, arteriovenous malformation

Question 8

What are the two key risk factors for subarachnoid hemorrhage

Answer 8

Smoking

Hypertension

Question 9

Name the 4 modifiable risk factors for subarachnoid hemorrhage

Answer 9

• Hypertension
• Smoking
• Alcohol abuse
• Substance misuse e.g. cocaine

Question 10

Name the non-modifiable risk factors for subarachnoid hemorrhage

Answer 10

• Sex: higher incidence in female
• Race: higher incidence in Japanese/Finnish populations
• Family history of aneurysms
• Genetic predisposition: seen in conditions such as sickle cell anaemia, Marfan syndrome, Ehlers-Danlos syndrome, autosomal dominant polycystic kidney disease
• Age: 45-70

Question 11

subarachnoid hemorrhage has a higher incidence in:

a) males
b) females

Answer 11

b) females

Question 12

What genetic conditions are a risk factor for subarachnoid hemorrhage

Answer 12

Sickle cell anaemia

Marfan syndrome

Ehlers-Danlos syndrome

Autosomal dominant polycystic kidney disease

Question 13

What is the key (red flag) symptom of a subarachnoid hemorrhage

Answer 13

• Sudden-onset or ‘thunderclap’ headache
  
  • Severe headache that reaches maximum intensity within seconds
  • Often described as the “worst headache of my life”
  • Described as a :blow to the back of the head”

Question 14

What are the 3 symptoms that make up the Meningism picture

Answer 14

• Headache
• Photophobia (difficult tolerating light)
• Neck stiffness

Question 15

What brings about a Meningism picture

Answer 15

Occurs when there is meningeal irritation

Question 16

Name the signs of subarachnoid hemorrhage

Answer 16

• Neck stiffness
• Cranial nerve palsy (e.g. third nerve palsy)
• Reduced consciousness (coma)
• Diplopia (double vision)
• Ptosis (dropping of upper eyelid)

Question 17

Name the two classic signs of meningism

Answer 17

Kernig’s sign

Brudzinski’s sign

Question 18

What two conditions cause a meningism picture

Answer 18

Bacterial meningitis

Subarachnoid haemorrhage

Question 19

What is the Kernig’s sign

Answer 19

It is one of the classic signs of meningism

It refers to the inability to fully extend at the knee when the hip is flexed at 90º due to pain due to the stretching of the meninges

Question 20

What is the Brudzinski’s sign

Answer 20

It is one of the classic signs of meningism

It occurs when on spontaneous flexion of the knees and hips on active flexion of the neck

Question 21

What is the gold standard investigation for subarachnoid haemorrhage

Answer 21

CT head

Question 22

If the CT head is negative, what other investigation must you conduct for subarachnoid haemorrhage

Answer 22

Lumbar puncture

Question 23

Describe what you would see on a CT head if a patient had a subarachnoid haemorrhage

Answer 23

• Hyperdense material (bright on CT) is seen filling the subarachnoid space.
• Most commonly the hyperdense material is apparent around the Circle of Willis, on account of the majority of berry aneurysms occurring in this region (~65%), or in the Sylvian fissure (lateral sulcus (~30%))

Question 24

The sensitivity of CT to the presence of subarachnoid blood is strongly influenced by both the amount of blood and the time since the haemorrhage.

CT head is very sensitive and specify if performed within how many hours from the time of symptom onset

Answer 24

Performed within 6 hours

Question 25

If CT is performed \> 6 hours from symptom onset, then what investigations must be conducted to exclude the diagnosis of subarachnoid hemorrhage

Answer 25

Lumbar puncture

Question 26

When is a lumbar puncture used in investigating subarachnoid haemorrhage

Answer 26

Used to confirm SAH if CT is negative, particularly if CT head was performed \> 6 hours since the time of symptom onset

Question 27

What are the two features from a lumbar puncture that would be suggestive of a subarachnoid haemorrhage

Answer 27

Raised red cell count Xanthochromia (the yellow colour of CSF caused by bilirubin)

Question 28

When should a patient be referred to neurosurgery for a subarachnoid haemorrhage

Answer 28

Referral to neurosurgery to be made as soon as SAH is confirmed

Question 29

What investigation is used once a subarachnoid haemorrhage is confirmed to locate the source of bleeding/ruptured aneurysm

Answer 29

CT intracranial angiogram

Question 30

Why is a CT intracranial angiogram important to do once a diagnosis of subarachnoid haemorrhage is made

Answer 30

Used once a subarachnoid haemorrhage is confirmed to locate the source of bleeding/ruptured aneurysm

Question 31

Name some of the complications of a subarachnoid haemorrhage

Answer 31

* Re-bleeding – most common in the first 12 hours * Cerebral vasospasm (also termed delayed cerebral ischaemia) – typically 7-14 days after onset * Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) * Seizures * Hydrocephalus * Death

Question 32

Cerebral vasospasm is a common complication of a subarachnoid haemorrhage. How long after a subarachnoid haemorrhage would vasospasm typically develop?

Answer 32

Typically 7-14 days after onset

Question 33

Rebleeding is the most common complication of a subarachnoid haemorrhage. How long after a subarachnoid haemorrhage would rebleeding typically occur?

Answer 33

Most common in the first 12 hours

Question 34

What is the initial management of subarachnoid hemorrhage

Answer 34

* ABCDE assessment * GCS \<8 – requires airway management

Question 35

Surgical intervention are used to treat the aneurysms with the aim of repairing the vessel that has caused the subarachnoid hemorrhage to prevent rebleed. Name the 2 surgical methods to repair the vessels

Answer 35

Coiling Clipping

Question 36

Coiling and clipping are two surgical techiques in which we use to repair the vessels that has caused the subarachnoid hemorrhage. Which one of these techniques are done under interventional radiology

Answer 36

Coiling

Question 37

Coiling and clipping are two surgical techiques in which we use to repair the vessels that has caused the subarachnoid hemorrhage. Which one of these techniques are done under **neurosurgery**

Answer 37

Clipping

Question 38

What is involved in the **coiling** surgical technique in manging subarachnoid haemorrhage

Answer 38

Done under interventional radiology Involves inserting a catheter into the arterial system (endovascular approach and placing platinum coils into the aneurysm and sealing it off from the artery

Question 39

What is involved in the **clipping** surgical technique in manging subarachnoid haemorrhage

Answer 39

Done by neurosurgery Craniotomy and microscopic assisted clipping of the aneurysmal neck

Question 40

A major part of managing subarachnoid haemorrhagic is treating the complications associated with them. One such complication is cerebral vasospasm. What do we do in order to prevent vasospasm?

Answer 40

21 days course of Nimodipine 60mg – one every 4 hours

Question 41

Nimodipine is used to prevent cerebral vasospasm - a complication associated with subarachnoid haemorrhage. What drug class is it and what is its mechanism of action

Answer 41

Calcium channel blocker that targets the brain vasculature

Question 42

A major part of managing subarachnoid haemorrhagic is treating the complications associated with them. One such complication is **hydrocephalus.** How do we manage it if this does occur

Answer 42

Accumulation of CSF in the ventricular system Insertion of a shunt to manage the hydrocephalus

Question 43

A major part of managing subarachnoid haemorrhagic is treating the complications associated with them. One such complication is seizures. How do we manage it if this does occur

Answer 43

Antiepileptic medications

Question 44

Coiling and clipping are two surgical techiques in which we use to repair the vessels that has caused the subarachnoid hemorrhage. Which technique is generally preferred and why?

Answer 44

Endovascular clipping is generally preferred over surgical clipping due to better long term survival rates

Question 45

What is the gold standard investigation in assessing for an underlying cause of the subarachnoid haemorrhage?

Answer 45

Digital Subtraction Catheter Angiography (DSA)

Question 46

Once a patient is diagnosed with subarachnoid haemorrhage, what is the essential next step (providing that you have already referred them to neurosurgery)

Answer 46

CT angiography