Subarachnoid Hemorrhage

and
Aneurysm
 Causes of the SAH

 Spontaneous SAH, 85% from ruptured

intracranial aneurysm
 Traumatic course of SAH
 SAH

 Coma-producing stroke
 Agonizing headache, develops instantaneous or
over minutes. Last for hours to days. Diffuse,
N&V, neck pain for some patients. +/-
LOC/Syncope
 Incidences

 Age range: 40-60

 ~25-50% mortality, at least 1/2 survivors with
permanent neurological deficit
 Affect females ~1.5 times more than male
 In HK, SAH accounts for ~6% in total stroke
population
Grading of SAH
 Fisher Grading of CT scan
1. No blood on CT
2. Diffuse blood, no thick blood clot
3. Dense collection of blood in subarachnoid space
4. Intracerebral or intraventricular clot, diffuse or
no blood in basal cistern
 CTA for aneurysmal SAH
Ideal screening examination:
 Easily available to optimize resources
 Can be do quickly in cases of UN-cooperative
patients
 Reasonably sensitive and specific (100% in
aneurysms 3mm or larger)

 Beware of contrast medium allergy or renal

failure
CTA
Digital subtraction angiography
DSA
Shape of Aneurysm
 Size of Aneurysm
 Saccular aneurysm usually classified as:
 Small: less than 12mm
 Large: 12-25mm
 Giant: larger than 25mm (less likely rupture)

 Majority of ruptured aneurysm ~5-15mm.

Rupture seldom occurs in less than 3mm in
diameter
 Size of Aneurysm
 Saccular aneurysm usually classified as:
 Small: less than 12mm
 Large: 12-25mm
 Giant: larger than 25mm (less likely rupture)

 Majority of ruptured aneurysm ~5-15mm.

Rupture seldom occurs in less than 3mm in
diameter
Where is the Aneurysm ? Why?
 Mx of Aneurysm
Clipping vs Endovascular coiling
Clipping
Coiling
Endovascular Coiling Vs Surgical Clipping

 Durability of coil unknow

 Rupture of aneurysm : similar
 Some area unable to introduce the microcatheter
into the aneurysm
 Difficult to control bleeding if ruptured
 Higher risk (×4) of requiring a 2nd procedure on
the same aneurysm
 Exceptational & Improvement
 MCA aneurysms would be preferentially
treated with neurosurgical clipping
 In coiling, special attention is made for tight
neck packing
 Aneurysm of size over 3mm and ratio of
aneurysm sac height to aneurysm neck diameter
more than 2 would be treated preferentially
with endovascular embolization
 Major complications
Rebleeding
 In 1st 24 hours 4.1%
 In 1st 2 weeks 19%
 In post onset 28 days ~30% rebleed
 If ruptured untreated 70% die
 Major complications
Cerebral vasospasm
 Delayed sustained contraction of cerebral
arteries
 It occurs post day 3-4 to 1st 2 weeks
Gold standard to assess cerebral vasospasm

DSA : gold standard

CTA : For no or severe spasm

MRA: artifact because of blood clot/coil/clips.

 Major complications
Delayed Ischemic Neurological Deficit (DIND)

 25% patients developed DIND, 50% die, 50%

with permanent neurological deficit
Monitoring of vasospasm
 Transcranial Doppler (TCD)
 Non-invasive
 Easy assessable
 Cheap

1.Lindegaard ratio:MCAFV/ICAFV if ＞ =3 vasospasm

indicated. If ＞ =6, severe vasospasm
2.MCAFV ＞ =120cm/s indicated, if ＞ =200cm/s severe
vasospasm
3.Increase MCAFV ＞ 50cm/s per 24hours or increase
100% of initial value
 Treatment
HHH therapy
 Hypervolemic, hypertensive, hemodilution
therapy
 If deteriorating despite HHH therapy --- ＞ DSA
 Balloon angioplasty
 Intra-arterial Papaverine (potent vasodilator) if
Ballon angioplasty is contraindicated
 Risk of Triple H Therapy
 Heart failure
 Pulmonary oedema
 myocardial infarction
 Major complications
Hydrocephalus

 Acute obstruction of CSF

EVD & ICP
 Major complications
Hyponatremia ＜ 135mmol/L
 Common in acute increase ventricular size and
increase ICP
 Na+< 120 in two reading continuously,
increase risk of seizure
 SIADH & CSW
 aggravated cerebral oedema/cerebral
vasospasm induce infraction
 Syndrome of Inappropriate Secretion of Anti-
diuretic Hormone
Hyponatremia because fluid overload/retention .

SIADH

Treatment replacement of sodium and fluid

restriction
 Cerebral Salt Wasting
This form of hyponatraemia is due to excessive
renal sodium excretion.

CSW

Sodium replacement no fluid restriction.