Subarachnoid Haemorrhage

Question 1

Presentation of SAH

Answer 1

a. Headache: sudden onset, severe, not previously experienced; with sentinel headache commonb. Reduced conscious state: due to immediate effects of SAH or evolving hydrocephalusc. Meningism: due to blood components irritant in subarachnoid space causing - headache, neckstiffness, vomiting, photophobiad. Focal neuro Sx

Question 2

What focal neurological Sx can be present and what are the causes?

Answer 2

– Intracerebral component to the bleeding• Frontal or temporal haematoma– Local pressure effects of the aneurysm• Especially third nerve palsy– Cerebral vasospasm• Delayed 2-7 days after presentation

Question 3

DDx of SAH

Answer 3

a. Meningitisb. Intracerebral haematoma: hypertensive or amyloid haematomac. Migraine, cluster headached. Other causes of sudden onset headache:- Headache with orgasm- Reversible cerebral vasospasm

Question 4

Causes of SAH

Answer 4

Ruptured cerebral aneurysm (70%)Ruptured AV malformation (10%)Unknown (15%)Rare causes (5%)- Spinal AV malformation- Arterial dissection- Tumour (erosion through BVs)- Bleeding diathesis

Question 5

Ix

Answer 5

CT

Question 6

What test would you do if the CT scan was normal?

Answer 6

NB: 2% of CT scans are normal (may be too small to see) Therefore would order a lumbar puncture to detect blood at 12 hours. Why wait? Need to wait for Hb to breakdown. - Subarachnoid blood due traumatic LP vs due to subarachnoid haemorrhage

Question 7

Management of SAH

Answer 7

Monitor and treat the Sx and complications of SAH:- pain, nausea, vomiting- Raised ICP and hydrocephalus Prevent bleeding

Question 8

What analgesia is safe in SAH?

Answer 8

mild opiates/paracetamol as don’t want to decrease conscious state

Question 9

What observations/monitoring is needed?

Answer 9

GCSBP: reduced BP to normal, monitor Cushing response

Question 10

What blood pressure parameters would you order?

Answer 10

Normotensive

Question 11

What further Ix do you need to do and when do you need to do them?

Answer 11

CT angiogramCerebral digital subtraction angiography (DCA)

Question 12

AFx of cerebral angiography

Answer 12

Contrast allergyRenal impairmentStroke risk (due to invasive procedure)

Question 13

Complication of cerebral aneurysm post treatment

Answer 13

Re-bleeding of cerebral aneurysm(50% pts rebleed within 6 weeks of 1st SAH; 25% pts within 2 weeks of 1st SAH)

Question 14

Management to prevent rebleed

Answer 14

1. Normotensive 2. Avoid raising ICP - avoid coughing, straining, vomiting, pain, agitation 3. URGENT diagnosis and treatment of theaneurysm– CT angiogram / formal catheter angiography– Surgical clipping of the aneurysm neck orendovascular coiling

Question 15

What is endovascular coiling?

Answer 15

Platinum wire coils are placed in the anuerysm angiographically to induce thrombosis therefore aneursym is not filled with blood, decreasing P and decreases risk of rupture - encouraging clot formation in situ