Nina T. Gentile, MD Associate Professor Department of Emergency Medicine Temple University Hospital

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Nina T. Gentile, MDAssociate ProfessorDepartme
nt of Emergency MedicineTemple University
Hospital School of MedicinePhiladelphia, PA

Nina T. Gentile, MD, FAAEM
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Subarachnoid Hemorrhage
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American Stroke Association Ad Council
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Vertebral artery angiogram. Arrows show
aneurysmal dilatation of intracranial portion of
the vertebral artery.
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Spontaneous SAH

• Rupture arterial aneurysm
• Rupture AVM
• Perimesenchymal vein or capillary bleeding

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• Saccular
• AVM
• Arteriosclerotic
• Mycotic
• Traumatic
• Dissecting
• Neoplastic
• Drugs

Sahs et al
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ACA 5
MCA 25
Ant CoA 25
Post CoA 25
PCA 2
VBA 13
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Clinical Manifestations
Ruptured aneurysm
headache
stiff neck
focal deficit
Ribeiro JA., et al, Acta Medica Portuguesa.
11(12)1085-90, 1998 Dec.
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Confusion/Lethargy

• Decreased alertness, Confusion, or Irritability
• Temporary
• Persistent
• Progressively worse to coma and death
• Syncope
• ? Mental Status Exam
• Six-Item Screen

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SAH Signs

• Abnormal vital signs
• Respiratory variation
• Hypertension
• Irregular heart rate

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SAH Signs

• Focal neurologic signs
• III nerve palsy IC/PCA aneurysm
• Hemiparesis, aphasia MCA aneurysm
• Paraparesis ACA aneurysm

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Warning or Sentinel Bleeds

• Up to 50 of patients with SAH report a distinct,
  severe headache in the days or weeks before the
  index bleed
• Milder sxs
• H/o Headaches

J Neurosurgery 1987
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Outcome of Patients Misdiagnosed and Correctly
Diagnosed With SAH

• Outcome Missed (n45) Correct Dx (n75)
  
• Excellent/good 24 (53) 68 (91)
• Fair 5 (11)
  4 (5)
• Poor
• (vegetative/dead) 16 (36) 3
  (4)
• Values are number () Plt.001

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Features of Disdiagnosed Patients
JAMA. 2004291866-8
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Features of Disdiagnosed Patients
JAMA. 2004291866-8
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Features of Disdiagnosed Patients
JAMA. 2004291866-8
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Who Needs Imaging?

• Sudden acute-onset headache
• Prospective studies report that 30 of patients
  complaining of the worst headache of their life
  had positive findings on CT.

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Who Needs Imaging?

• Occipital location
• Worsens with Valsalva
• Awakens from sleep
• Associated with syncope, nausea, or sensory
  distortion.

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Computed Tomography

• Sensitive for blood
• day of the bleed? 95
• within 12 hours of symptom onset ? as high as
  98.
• Sensitivity drops when
• symptoms are days in duration
• amount of bleeding is small ? 85
• study is difficult to interpret

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Ruptured Ant CoA aneurysm
?
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SAH 20 ruptured right PCA
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Normal Circle of Willis 3-D CT-A
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Normal Circle of Willis 3-D CT-A
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3-D CT-A
SAH 20 ruptured ACA aneurysm
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3-D CT-A
SAH 20 ruptured PCoA aneurysm
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Lumbar puncture and CSF Exam

• LP whenever the CT or CTA is negative, equivocal,
  or technically inadequate
• Blood or red blood cells in the first 8 hrs.
• Xanthochromia or an inflammatory reaction when
  CSF exam delayed

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Lumbar Puncture
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SAH Complications

• Multisystem Failure
• Increased Intracranial Pressure
• Rebleeding
• Vasospam

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Multisystem Complications
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Increased Intracranial Pressure
Major Cause of Death
Fluid restriction?
ICP monitoring
Raising head
Hypothermia
Hypocarbia
Barbiturate coma?
Ventriculostomy
Steroids?
Mannitol
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SAH Complications
VASOSPASM
REBLEEDING
Kassell et al
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Rebleeding

• Leading cause of death or morbidity during the
  first 2 weeks after SAH
• Incidence
• 4-10 in 24 hours
• 15-25 in 2 weeks
• 2-3 after 1 month for 10 years
• Presents with sudden change in neurological
  status, new headache and coma.

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Treatment Prevent Rebleeding

• Aneurysmal Clipping
• Endovascular Coiling
• Hematoma Evacuation
• Procoagulatants

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ISAT Study

• Patients with ruptured intracranial aneurysms
• Dependency or Death at 1 year
• Neurosurgical Clipping 243/793 (30.6)
• Endovascular Coiling 190/801 (23.7)

Lancet. 2002360(9342)1267-74
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Hematoma Evacuation
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Hematoma Evacuation
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Prevent Rebleeding
 Potential role of NovoSeven in the prevention of
rebleeding following aneurysmal subarachnoid
haemorrhage.
Blood Coagul Fibrinolysis. 2000 Apr11 Suppl
1S117-20.
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SAH COMPLICATIONS
Vasospasm
Normal Caliber
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Treatment Prevent Vasospasm

• Maintain BP
• Oral Nimodipine
• Intraoperative t-PA?

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Calcium Channel Blockers

• ? BP
• ? Intracellular and transmembrane calcium fluxes
• Oral Nimodipine is ideal
• crosses BBB and has limited cardiovascular
  effects
• reduces the incidence of cerebral infarction and
  improves outcome by 40 when administered within
  4 hrs of SAH.

Cochrane Database Syst Rev. 2000(2)CD000277
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Prevent Vasospasmt-PA?

• Instill 1-10 mg t-PA into the basal cistern after
  aneurysm clipping
• Facilitates earlier clearing of blood clots and
  ventricular drainage
• Can avert cerebral ischemia after SAH

Neurosurgery. 2004 Sep55(3)532-7 Neurol
Neurochir Pol. 200034(6 Suppl)41-7
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Teaching Points

• SAH is often misdiagnosed
• CT is sensitive but not fool-proof
• LP for patients with normal or equivocal CT
• Early angiography and IR/ Neurosurgery eval to
  facilitate intervention
• Treat to prevent multisystem and neurological
  complications of SAH.
• Attend to the airway and BP
• Monitor and Control ICP
• Prevent Re-bleeding and Vasospasm

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Questions?? www.ferne.orgferne_at_ferne.org
Nina Gentile, MDngentile_at_temple.edu 215 707
8402
Nina T. Gentile, MD, FAAEM