Subarachnoid Haemorrage

Epidemiology
8-9/100,000
Typical age: 35-65
Risk factors:
Age Adult polycystic kidney disease
Hypertension Marfans/Ehlers Danlos syndrome
Smokers Familial

Aetiology:
Berry Aneurysm
o Commonest cause
o Common sites: Junction of posterior communicating artery with Internal
carotid, anterior communicating with the anterior cerebral artery, or
bifurcation of middle cerebral artery
o 15% are multiple
o Hereditary
Traumatic and infections aneurysms
Clotting disorder (e.g. Warfarin)
Dural Arterio-venous malformation

Presentation:
Worst ever headache
Coma /drowsiness
Sudden death
Vomitting/nausea
Seizures

Examination:
Meningism
o Neck stiffness, photophobia, positive Kernigs sign (flex hip to 90o, flexion of
the knee past 90o will then be painful).
Signs of increased ICP
Presence of subhyaloid haemorrages on funduscopy
Late papillodema

DDx
Only 25% in primary care with a thunderclap headache have SAH
50-60% have no cause found
Rest have:
o Meningitis
o Migraine
o Intracerebral bleeds
o Cortical vein thrombosis
Diagnosis
CT Scan
o Sensitivity 95% in first 24 hours, 90% in 48hours. If negative, do Lumbar
Puncture
Lumbar Puncture
o Measure opening pressure
o Look for evidence of blood and/or Xanthochromia (After 12 hours)
If CT or LP positive
o Send for CT angiogram or digital subtraction angiography
Note: sensitivity of CT Scan goes down with delays

Management
Subarachnoid haemorrhage is a life threatening condition which requires intensive care.
Maintain Cerebral Perfusion Pressure
o Aim for Systolic Blood Pressure >160mmHg, keep patient well hydrated
Endovascular coil embolization
o Preferred due to increase survival over 7 years but does increase to risk of
rebleed (compaired to clipping)
Surgical clipping
Calcium channel blockers
o Nimodipine
o Reduces vasospasm and mortality from cerebral ischaemia
Stool softeners
o Docusate, Senna
o These prevent straining and thus reduce the risk of a rebleed
Antitussives
o Coughing increases chance of rebleed
o Codeine
Complications
Rebleeding
o 20% of patients suffer this within first few days
o Commonest cause of death
Hydrocephalus
o 15% of acute SAHs
o Blocking of arachnoid granulations
o Treat with ventricular or lumbar drain
Cerebral ischaemia
o Due to vasospasm (nimodopine helps prevent)
o Can cause permanent CNS deficit commonest cause of morbidity
Hyponatraemia
o Common but should not be managed with fluid restriction seek expert help.
Prognosis