CLINICAL AND NEUROIMAGING
STUDIES IN CASES OF SPONTANEOUS SUBARACHNOID HAEMORRHAGE
INTRODUCTION
Subarachnoid haemorrhage (SAH), mostly from
aneurysms account for about 4.5 – 13% of all strokes.
The incidence of SAH has remained stable over
the last 30 years.
The reported incidence of SAH in the US,
Finland & Japan is high, while it is low in New
Zealand and Middle East.
INTRODUCTION
Incidencen/100,000 patients 95% CI
Finland22.0
USA12.0
Japan23.0
New Zealand14.3
Australia26.4 ‡
Netherlands7.8
Iceland8.0
Greenland Eskimo9.3
Denmark3.1
Faeroe Islands7.4
Indians4.3
Qatar5.1
Overall10.5‡ Not adjusted for sex & age to the same reference population
INTRODUCTION
Aetiology:
Ruptured intracranial aneurysms. (Commonest)
Cerebral AVMs.
CNS vasculitis.
Cerebral artery dissection
Rupture small superficial artery
Rupture of an infundibulum
Coagulation disorders.
INTRODUCTION
Dural sinus thrombosis &/or AV fistula.
Spinal AVMs
Pretruncal non-aneurysmal SAH
Rarities: - Tumours
- Sickle cell disease
- Cocaine abuse
- Atrial myxoma
- Pituitary apoplexy
No cause in 7 – 10%
INTRODUCTION
Aetiology:
Risk factors:
Unruptured aneurysms Hypertension
Smoking Race
Age Gender
Alcohol consumption ADPCK
Connective tissue disorders
INTRODUCTION
Clinical presentation
Meningismus 64%
Coma 52%
Nausea & vomiting 45%
No localization sign 39%
Global headache 32%
Occipital headache 21%
INTRODUCTION
Clinical presentation
Motor deficit 17%
Dysphasia 13%
Confusion 12%
Intraocular haemorrhages 12%
Anisocoria 12%
INTRODUCTION
Reflex changes 19%
Clinical presentation
Lateralized headache 8%
Third nerve palsy 7%
Sensory disturbance 5%
INTRODUCTION
Papilloedema 11%
Homonymous hemianopsia 9%
Complications
Ischaemic deficits 27%
Hydrocephalus 12%
Brain swelling 12%
Recurrent haemorrhage 11%
Intracranial hematoma 8%
Pneumonia 8%
INTRODUCTION
Gastrointestinal haemorrhage 4%
SIADH 4%
Pulmonary oedema 1%
Seizures 5%
INTRODUCTION
Complications
Investigations
Computed Tomography (CT)
Hydrocephalus 20%
The presence of intraventricular blood (13-28%)
Intraparenchymal blood (20-40%)
Subdural blood (1 - 3%)
INTRODUCTION
INTRODUCTION
Investigations
Computed Tomography (CT)
The pattern of SAH
Blood in cistern and fissures
With presence of multiple aneurysms it detect which one bled
INTRODUCTION
Investigations
Lumbar puncture (LP):
Elevated opening pressure
Xanthochromia
Elevated proteins
RBCs > 100.000 cm 3
INTRODUCTION
Investigations
CT angiography (CTA):
Suspicion of an aneurysm on conventional CT
Follow up of previously diagnosed aneurysm not planned for surgeryFollow up of aneurysm anatomy after surgery
Detection of ruptured aneurysms
Screening
INTRODUCTION
Investigations
MRI:
A unique method for identifying aneurysm in patient who not reffered till after 5 – 10 days, and brain CT showed no subarachnoid blood.
FLAIR MRI is more sensitive than CT in detection of acute SAH.
INTRODUCTION
Investigations
MRA:
For detecting aneurysm with sensitivity 85% and specificity around 90%.
For vasospasm identification the sensitivity is 92% and specificity 97%.
INTRODUCTION
Investigations
TCD:
Highly specific 100%, but relatively insensitive in detecting vasospasm.
Assess the intraaneurysmal dynamics.
INTRODUCTION
Investigations
Cerebral angiography:
The gold standard for the diagnosis of the intracranial aneurysm.
Negative in 20%.
INTRODUCTION
Investigations
Cerebral angiography:
Complications:
- Hypersensitivity to contrast agent.
- TIA
- TGA
- Death 1/20 – 40.000
Management
General
- Nursing - Nutrition
- Blood pressure - Fluid and electrolytes
- Pain
- Prevention of DVT, or pulmonary embolism
INTRODUCTION
Vasospasm
Prophylactic treatment:
- CCB (Nimodipine) - Olprinone
- Tirilazed
- Other investigational drugs (FK 506, TBC 11.251, L-Argininive monoclonal antibodies. Defferoxamine and prostacyclines, AVS, CGU.
INTRODUCTION
Management
- Intrathecal sodium nitroprusside
- Nitroglycerine
- Cyclosporin - Steroids
INTRODUCTION
Vasospasm
Curative treatment:
Management
- Hyperdynamic Therapy (Triple H therapy)
- Barbiturate coma
- Cisternal irrigation
- Gene therapy
- Angioplasty
- Intra-arterial injection of vasodilator
- Intra-aortic counterpulsation
INTRODUCTION
Vasospasm
Curative treatment:
Management
Antifibrinolytic drugs (TEA, EACA)
Early surgical intervention
INTRODUCTION
Management
Rebleeding
Conservative
Repeated LP
Vetriculostomy
Shunt
INTRODUCTION
Management
Hydrocephalus
Hyponatraemia
Cardiac complications
Pulmonary complications
INTRODUCTION
Management
Systemic complication
Trapping
Proximal ligation (hunterian ligation)
Thrombosing aneurysm with GDC & Balloon embolization.
INTRODUCTION
Management
Endovascular & nonsurgical techniques to treat the aneurysm
Clipping
Wrapping
Coating
INTRODUCTION
Management
Surgical treatment
AIM OF THE WORK
This work is carried out to evaluate the
clinical presentation and various diagnostic
procedures of spontaneous subarachnoid
haemorrhage.
AIM OF THE WORK
PATIENTS & METHODS
PATIENTS & METHODS
PATIENTS & METHODS
PATIENTS WERE SUBJECTED TO
History taking
Laboratory investigations
Neurological examination
Lumbar puncture
CT scanning & CTA
MRI FLAIR
MRA
4 vessels angiography
PATIENTS & METHODS
Table : Hunt and Hess scale
GradeDescription
IAsymptomatic or mild headache and slight nuchal rigidity
IICr. N. palsy, moderate to severe headache, nuchal rigidity
IIIMild focal deficit, lethargy, or confusion
IVStupor, moderate to severe hemiparesis, early decerebrate rigidity
VDeep coma, decerebrate rigidity, moribund appearance
Modified classification adds the following:
0Unruptured aneurysm
IaNo acute meningeal/brain reaction, but with fixed neuro deficit
Add one grade for serious systemic disease (eg HTN, DM, COPD, or atherosclerosis) or severe vasospasm on arteriography
PATIENTS & METHODS
RESULTS
SAH
Number and percentage of stroke patients admitted to the neurology department in Mansoura Emergency University
Hospital in the period of the study
Haemorrhagic stroke Ischemic stroke
RESULTS
Male
Sex distribution
Female
RESULTS
60 - 69 >70
Age distribution in males
30 - 39 40 - 49 50 - 59
RESULTS
60 - 69 >70
Age distribution in females
30 - 39 50 - 5940 - 49
RESULTS
0
5
10
15
20
I II III IV V
Males Females
Sex distribution in the different grade of the studied patients
RESULTS
0
20
40
60
80
100
No
%
GI GII GIII GIV GV Total
Clinical Grading System according to H & H.
RESULTS
0
20
40
60
80
I II III IV V
Mean SD SE
Mean age in the different grade of the studied patients
RESULTS
6 PM : 12 AM
percentage of patients according to time of onset of SAH
12 AM : 6 AM 6 AM : 12 PM
12 PM : 6 PM
RESULTS
0
1
2
3
4
5
6
7
8 No. of patients
Incidence of SAH in the 24 hours SAH
RESULTS
0
10
20
30
40
Hypertension
Dyslipidemia
Diabetesm
ellitus
Smoking
Hyperuricemia
Drug abuse
Family history
Collagenvasculardisease
Bleedingdiasthesis
Frequency of risk factors
RESULTS
No. ofdeath
%
First week
Second week
Third week
Fourth week
Total
30 days case fatality rate
RESULTS
DEATH (NO)
DEATH (YES)
TOTAL
I
%w
thin
GR
AD
E
II
%w
thin
GR
AD
E
III
%w
thin
GR
AD
E
IV
%w
thin
GR
AD
E
V
%
wth
in G
RA
DE
To
tal
%w
thin
GR
AD
E
The relation between the clinical grades and mortality rate
RESULTS
0
10
20
30
40
%Rebleeding Vasospasm Initial haemorrhage Others
Causes of short term mortality
RESULTS
0
20
40
60
80
100
%
ASAH PMH Negative
CT finding in our series
RESULTS
0
10
20
30
40
50
60
70
80
%
MCA aneurysm A com A aneurysm Multiple aneurysms
Vasospasm No aneurysm AVM
MRA finding of the examined patients
RESULTS
0
10
20
30
40
50
60
%
MCA aneurysm PCA aneurysm
A Com A aneurysm ICA aneurysm
MCA & A Com A aneurysm Negative
Conventional angiography finding in our series
RESULTS
CASE 1
RESULTS
RESULTS
RESULTS
RESULTS
CASE 2
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
CASE 3
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
CASE 4
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
CONCLUSIONS
Sudden , explosive headache is a cardinal but
nonspecific feature in the diagnosis of SAH : in
general practice , the cause is innocuous in nine out
of the ten patients in whom this is the only symptom
The incidence of subarachnoid haemorrhage is
3.8% of all strokes in our locality ,and presenting
12.4% of the haemorrhagic strokes.
CONCLUSIONS
48% of patients presented by sudden , severe
headache , nuchal rigidity and cranial nerve
palsy , while 24% presented by stuporous
consciosness and severe hemiplegia , and only 6
% with deep coma .
Most patients are below sixty years of age , and
women are more suffered . Risk factors are the
same as for stroke in general ; genetic factors
operate in only a minority .
CONCLUSIONS
30 day case-fatility is 46% , the majority of them in
the first week after admission due to rebleeding
and the effect of this initial haemorrhage .
Hypertension , smoking , diabetes, age and
dyslipedemia are the main risk factors .
CONCLUSIONS
MRI FLAIR is superior than CT in detecting SAH in
subacute phase where the patient come after the
onset by one or two weeks .
Four-Vessels angiography more sensitive in
detecting intracranial aneurysms in comparison to
MRA.
CT scanning is mandatory in all , to be followed by
(delayed ) lumber puncture if CT is negative .
CONCLUSIONS
RECOMMENDATIONS
The Clinician should have a high index of
suspicion that a sudden , severe , unexplained
headache in any patients could represent an
acute subarachnoid haemorrhage .
If the CT scan is positive , lumber puncture is
unnecessary and dangerous due to risks of
aneurysm rebleeding or transetentorial brain
herniation .
RECOMMENDATIONS
Once the diagnosis is confirmed with a CT scan , a
neurosurgeon who can ultimately treat the patient
should be contacted immediately . Delay in
transfer may prove fatal because of potential for
aneurysm rebleeding prior to intervention
RECOMMENDATIONS
If the CT scan is negative , lumber puncture may
be helpful if the history of ictal headache is not
typical of subarachnoid haemorrhage
RECOMMENDATIONS
Blood pressure must closely monitored and
controlled following SAH . Hypertension will
increase the chance of catastrophic rebleeding .
Blood pressure control should be initiated
immediately upon diagnosis of SAH.
RECOMMENDATIONS
Preoperative medications include prophylactic
anticonvulsants, and antihypertensives as needed .
Not initiate antifibrinolytic therapy unless surgery is
not considered within 48 hours of initial SAH.
RECOMMENDATIONS
All X-rays , MRI scans , and lab work sent with the
patients to avoid needless repetition .
Surgery or endovascular coiling to obliterate the
ruptured aneurysm should performed as soon as
possible after the onset of SAH. Poor grade
patients , grades 4 and 5 , are treated non-
operatively or neurointerventionally until their
clinical condition improves .
THANK YOU
Top Related