Subarachnoid Heamorrhage SAH

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Nonaneurysmal causes of SAH 25%

• Trauma

• Arteriovenous malformation

• Intracranial arterial dissection

• Cocaine and amphetamine use

• Mycotic aneurysm (septic)

• Central nervous system vasculitis

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Risk factors

• Hypertension OR-2,6

• Smoking OR-2,2

• High alcohol intake OR-1,5

• First degree relatives

• Ehlers-Danlos, Marfan’s syndrome, pseudoxantoma elasticum,

neurofibromatosis t. 1, polycystic kidney

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WFNS scale

• Grade 1 - Glasgow Coma Score (GCS) of 15, motor deficit absent

• Grade 2 - GCS of 13-14, motor deficit absent

• Grade 3 - GCS of 13-14, motor deficit present

• Grade 4 - GCS of 7-12, motor deficit absent or present

• Grade 5 - GCS of 3-6, motor deficit absent or present

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• SAH is preceded in about 10% of the cases by a “sentinel

headache”or warning leak, an

episode of headache similar to that of SAH,and preceding it by days or weeks.

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Misdiagnosis

20 % !!!

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Perimesencephalic pattern of SAH

• venous origin or due to intramural dissection

• benign course

• it can be

complicated by

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!!!! In 20-25% patients in acute stage the sight of bleeding will not be find in clasical

arteriography (due to vasospasm, slot in aneurysm, and misinterpretation)

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Management protocol for acute SAH

• Control elevated blood pressure to prevent rebleeding

• Intravenous hydration

• Check complete blood cell count,

electrolytes (hyponatremia), CK-MB

• Vasospasm prophylaxis (nimodipine 60 mg p.o. every 4 hrs for 21 days)

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Triple H therapy

• Hypertension 160mmHg

• Haemodilution

• Hypervolaemia

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Recurrent Hemorrhage

• If the aneurysm is not treated, the risk

• of rebleeding within 4 weeks is estimated to be of 35–40%

• After the first month the risk decreases

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surgery vs endovascular

• < 60

• MCA

• wide neck of aneyrysm

• large ICH

• old age

• bad condition

• aneurysm in posterior localization (basilar artery)

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Asympyomatic Aneurysms

• Contrary to current beliefs, aneurysms are not congenital but develop continuously during

lifetime.

• Unruptured aneurysms have a risk of rupture of ~1%/year, depending on their size.

• Current evidence indicates that in patients with a life expectancy of at least 20 years, only those in the anterior circulation < 7mm should be left untreated.

• Screening for unruptured aneurysms is