Subarachnoid Hemorrhage

Diagnosis

Approximately 30 to 50 percent of patients report a history of a sudden and severe headache (the sentinel headache) that precedes a major SAH by 6 to 20 days

CT (sensitivity declines over time) -> Lumbar Puncture if negative
MRI sensitivity especially > 4 days

LP:
The classic findings of SAH are an elevated opening pressure and an elevated red blood cell (RBC) count that does not diminish from CSF tube one to tube four. The differential of RBC between tubes one and four, and immediate centrifugation of the CSF can help differentiate bleeding in SAH from that due to a traumatic spinal tap
Most sensitivity 12 hours after event (less sensitive early on)
WBC-to-RBC ratio that is consistent with the normal circulating WBC-to-RBC ratio of approximately 1:1000
xanthochromia
LP findings can be negative in approximately 10-15% of patients with SAH

Hunt and Hess Grading System

Grade Neurologic status
1 Asymptomatic or mild headache and slight nuchal rigidity
2 Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy
3 Drowsy or confused, mild focal neurologic deficit
4 Stuporous, moderate or severe hemiparesis
5 Coma, decerebrate posturing

Orders
CBC, BMP, IRN,PTT, blood type and screen, troponins, ecg, ABG is pulmonary compromise
CXR
CT, LP

 

Treatment
ICU admission
Neuro checks
Intubation for GCS < 8
Pneumatic compression stockings
Heparin PPX 24 hours after aneurysm treatment
IVF for euvolemia and normal electrolyte balance
stool softeners
bedrest
analgesia
GI PPX
Control Hyperglycemia
Hemoglobin transfusion goal (one study found 11.5 g/dl to be safe vs. 10)
ECG/trop with FU

 Nimodipine 60 mg every four hours is administered to all patients with aneurysmal SAH. Give for 21 days.

Reverse anticoagulation (vit K, FFP)

The 2012 American Stroke Association guidelines suggest that a decrease in systolic blood pressure to <160mm Hg is reasonable [7]. When blood pressure control is necessary, the use of vasodilators such as nitroprusside or nitroglycerin should be avoided because of their propensity to increase cerebral blood volume and therefore intracranial pressure. Labetalol, nicardipine, enalapril are preferred.

One study’s results suggest that this CPP threshold may be 70 mmHg
In the absence of ICP measurement, antihypertensive therapy is often withheld unless there is a severe elevation in blood pressure

Hemodynamic augmentation does not appear useful for the prevention of vasospasm, but may be appropriate in the treatment of symptomatic vasospasm (with pressor agents such as phenylephrine or dopamine)

Seizure PPX is debatable

we suggest initiating statin treatment (pravastatin 40 mg daily or simvastatin 80 mg daily) within 48 hours of aneurysmal SAH and continuing until discharge from intensive care (debatable)

Course
Rebleed (8-23% of patients) - acute deterioration in mental status with new CT findings

Vasospasm
"triple-H" therapy, included modest hemodilution, induced hypertension and hypervolemia instituted in an effort to raise the mean arterial pressure and thereby increase cerebral perfusion. More recently, the focus has shifted toward maintenance of euvolemia using crystalloid or colloid solution, and induced hypertension with vasopressor agents such as phenylephrine, norepinephrine, or dopamine

Delayed cerebral ischemia (DCI)
40-60% of patients
Single corticol infarct vs. multiple widespread infarcts
Secondary to vasospasm in the 3 to 8 day timeperiod after first event

Hydrocephalus

Venticular drain for deteriorating level of consciousness

Increased ICP

Seizures
6 to 18 percent of patients with SAH
Patients with acute seizures after SAH are treated with AEDs to prevent recurrence. Agents such as phenytoin, levetiracetam, carbamazepine, and phenobarbital are typically used
subclinical seizures requires a high index of suspicion

Hyponatremia
Thus, hyponatremia is treated with isotonic saline, or, if necessary, hypertonic saline
Cerebral salt-wasting is less common than SIADH in this setting and is characterized by volume depletion

Prognosis
Subarachnoid hemorrhage (SAH) is associated with a high mortality rate [58]. A systematic review found that the average case fatality rate for SAH was 51 percent [76]. Approximately 10 percent of patients with aneurysmal SAH die prior to reaching the hospital, 25 percent die within 24 hours of SAH onset, and about 45 percent die within 30 days
Seizures occur during the first 24 hours in less than 10 percent of patients, but are a predictor of poor outcome
SAH may also present as sudden death; at least 10 to 15 percent of patients die before reaching the hospital.
The combination of vitreous (preretinal) hemorrhages with SAH is known as Terson's syndrome and implies a poorer prognosis.

 

The Mandatory Disclaimer: All information on this website is purely for educational and training purposes. Use best clinical judgement, the most current reference articles, medical standards of care, and specialist consultations when making clinical decisions for your patients.

Last Updated August 14, 2015