SUBARACHNOID HEMORRHAGE

DIAH MUSTIKA HW SpS,KIC

INTENSIVE CARE UNIT of NAVAL HOSPITAL dr RAMELAN SURABAYA

EPIDEMIOLOGY

Subarachnoid hemorrhage include the subset of intracranial hemorrhage

Traumatic SAH : traumatic brain injury

Spontaneous SAH :

- Ruptured intracranial aneurysm (75-80%)

- Cerebral arteriovenous malformation (AVMs; 4-5%)

- Carotid or cerebral dissection

- Coccaine use

- Sickle cell disease

- Pituitary apoplexy

Risk Factor of aneurysmal SAH

Increasing age

Smoking: Relative risk is 3.0 for men, 4.7 for women

African American

Moderate to excessive alcohol intake

Hypertension

Cocaine use

Autosomal dominant polycystic kidney disease (ADPKD)

Fibromuscular dysplasia (FMD)

Arteriovenous malformation

Moyamoya disease

Connective tissue disease: Ehlers-Danlos type IV, Marfans syndrome, pseudoxanthoma elasticum

Multiple family members with intracranial aneurysms

Coarctation of the aorta

Osler-Weber-Rendu syndrome

Atherosclerosis

Bacterial endocarditis

CLINICAL PRESENTATION

Headache : sudden, severe, unremitting headache accompany with nausea and vomiting

Warning headache or sentinel leak

Photophobia

Neck stiffness

Meningismus

Impairment of consciousness

Cranial neuropathies

Seizure

DIAGNOSIS

Simple nonenhanced brain CT scan

Lumbar puncture if negative head CT scan but the presentation is typical RBC> 100000 cells/mm3 in 3rd tube and xanthochromia

CT Angiography (CTA)

Magnetic Resonance angiography (MRA)

Conventional Cerebral angiography gold standard

CA is negative in 10-15% in aSAH

PROGNOSTIC INDICATORS

Hunt and Hess Classification Scale

Grade Neurologic Status %risk of death I Asymptomic; or minimal headache and slight nuchal

rigidity 11

II Moderate to severe headache; nuchal rigidity; no

neurologic deficit except cranical nerve palsy 26

III Drowsy; minimal neurologic deficit 37

IV Stuporous; moderate-to-severe hemiparesis; possibly

early decerebrate rigidity and vegetative distirbance 71

V Deep coma; decerebrate rigidity; moribund

appearance 100

CRITICAL CARE MANAGEMENT

GCS 8 or unable to protect the airway should be intubated

Anticonvulsant prophylaxis

Blood pressure should be controlled aggressively. Hypotension

or hypertension should be avoided

Coagulation parameters should be examined and corrected

promptly

Give the stool softener

Pain management should be optimized

ICU

Complication and its therapy

Rebleeding

Broderick et al , 22% aSAH mortalities as a result of rebleeding

First 24 hours the risk is 4% and 1.5% per day for the following 13 days

The first 14 days the total risk of rebleeding is 15-20% and at 6 months is 50%

In the longterm, rebleeding at 3% per year and mortality is 2% per year

Treatment for prevention rebleeding is aneurysm obliteration (open aneurysm clipping or endovascular coil embolization procedures)

Hydrocephalus

communicating

obstructive

Treatment : External Ventricular Drainage (EVD)

50% improve spontaneously

Vasospasm :

o inflammatory reaction in blood vessel bathed in subarachnoid

blood, resulting in luminal narrowing

o 60- 70% after SAH, maximal severity in 2nd weeks after SAH

and typically resolves spontaneously in 3rd or 4th weeks

o Vasospasm cause death or serious disability Delayed Ischemic Neurological Deficit (DIND)

o Demonstrated radiographycally by transcranial Doppler (TCD),

cerebral angiography or CT angiography

o Treatment : hyperdynamic therapy or triple H therapy

(hypertension, hypervolemia and hemodilutions)

o Administration 23,4% saline improve CBF, CPP and decrease ICP significiantly at 90 and 180 minute after administration. Limited by hiperchloremia, hypernatremia and hyperosmolality

o Selective Calsium Channel Blocker (nimodipin) improve outcome by measure Glasgow Outcome Scale (GOS)

o Endovascular and surgical treatment if hyperdynamic and pharmacologic fail to reserve neurologic defisit

OUTCOME

Fairly poor as a whole

Overall mortality of aSAH is 45-50%

The most common predictor of death is the clinical

conditions at presentation, age, medical morbidities,

severity of hemorrhage on CT and aneurysm type

THANK YOU