Subarachnoid Heamorrhage SAH

AHA & Piotr Szczudlik MD

Nonaneurysmal causes of SAH 25%
•Trauma
•Arteriovenous malformation
•Intracranial arterial dissection
•Cocaine and amphetamine use
•Mycotic aneurysm (septic)
•Central nervous system vasculitis
•Coagulation disorders

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 disease

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

•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.

Misdiagnosis
20 % !!!

Perimesencephalic pattern of SAH
•venous origin or due to intramural dissection
•benign course
•it can be complicated by hydrocephalus

!!!! 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)

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)

Triple H therapy
•Hypertension 160mmHg
•Haemodilution
•Hypervolaemia

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
gradually from 1–2%/day to 3%/year

surgery vs endovascular
•< 60
•MCA
•wide neck of aneyrysm
•large ICH
•old age
•bad condition
•aneurysm in posterior localization (basilar artery)

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 controversial.

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