Subarachnoid Hemorrhage and It’s Complications

Diana Greene-Chandos, M.D.Director of Neuroscience Critical CareAssistant Professor of Neurosurgery and NeurologyThe Ohio State University Wexner Medical Center

Objectives

Describe the underlying pathology and symptoms of subarachnoid and hemorrhagic stroke

Identify risk factors associated with spontaneous intracerebral hemorrhage.

Describe the factors associated with hematoma expansion and poor outcome.

Understand the role and indications for surgical hematoma evacuation. Identify when additional imaging is needed after intracerebral

hemorrhage. Define stroke and understand its natural history Discuss the risk factors and pathogenesis of vascular disease

The Subarachnoid Space

The interval between the arachnoid membrane and pia mater.

More generous in the spine

Or It’s a Great Name for a Band

Bleeding in the Subarachnoid Space

Trauma (most common etiology) Aneurysmal Benign perimesencephalic

Traumatic SAH

Traumatic SAH

Tends to happen more commonly with moderate to severe head trauma

Typically associated with other types of brain injury such as contusions, subdural hematomas and/or diffuse axonal injury

Typically associated with additional body or head and neck trauma.

Low risk of delayed ischemic deficits but can have cerebral salt wasting syndrome

Aneurysmal SAH

5% of population Rupturing is more common in women overall and in men

under the age of 40

Overall Aneurysmal SAH Prognosis Among 100 typical patients with a-SAH

33 will die before receiving medical care 20 will die or remain incapacitated from initial SAH 17 will deteriorate (50% recovering and 50% with severe

neurological deficits) 30 will do well

Cerebral Aneurysms

Most common sites for cerebral aneurysms

Other tidbits about aneurysms

Multiple aneurysms present 14-24% of the time 7-20% of of pts with a ruptured aneurysm have a

first or second degree relative with an aneurysm If you are a first degree relative of someone with

a ruptured cerebral aneurysm risk of having an aneurysm is 4 times higher

Screening should occur in people with 2 or more first degree relatives with cerebral aneurysms or with 1 relative and tobacco abuse history +/- uncontrolled hypertension.

Risks for cerebral aneurysm formation Hypertension Tobacco abuse Polycystic Kidney Disease Coarctation of the Aorta Fibromuscular Dysplasia Pseudoxanthoma Elasticum Marfan’s syndrome

Risks for cerebral aneurysm rupture

Surges in blood pressure Strenuous activity Size greater than 7mm

The symptoms..

Sudden severe headache Usually occipital Nuchal pain also present Vomiting Decreased alertness

Sentinel Hemorrhage

31% of patients have a sentinel headache 50% of patients with a sentinel hemorrhage are

misdiagnosed by physicians.

Focal Neurological Deficits with Cerebral Aneurysms

Bitemporal Hemianopsia Basilar bifurcation

Weber’s Syndrome Giant SCA

Hemiparesis and Aphasia or Sensory Neglect Giant MCA Aneurysms

Third Nerve Palsy (Pupil involved): Intracranial ICA PCOM SCA

Diagnosis of Aneurysmal SAH

Head CT is BEST…. Do not hesitate to do an LP if there is any doubt…collect

Tube #1 and Tube #4 for cell count with differential Note: it may take up to 12 hours after onset of HA for

xanthrochromia to develop if just color is being looked at Spectrophotometry will quantify the amount of

hemoglobin and bilirubin and is independent of age of SAH.

CT example of Aneurysmal SAH

The Fisher Grade

I.....No blood evident on CT II….Blood less than 1mm at maximal width on CT III….Blood greater than 1mm maximal width on CT IV….Any blood width with IVH or parenchymal extension

The Hunt-Hess Grade

I…..Asymptomatic or Minimal HA and slight nuchal rigidity

II….Moderate to Severe HA, nuchal rigidity, no neurological deficit other than CN

III….Drowsiness, confusion or mild focal deficit

IV….Stupor, moderate to severe hemiparesis V….Deep coma with posturing

You’ve confirmed SAH…now what?

Admit to NCCU…no matter what. Keep the patient calm, quiet and pain free. SBP must be kept below 160 systolically Minimize procedures Best drugs for bp

Labetolol 10-20mg iv q 15 min prn Hydralazine 10 mg iv q 20 min prn If 3 doses required within 2 hours start Nicardipine

drip at 5mg/hr and titrate to goal bp

Confirmation of an Aneurysm

• CT angiography will help the angiographer know where to focus (but avoid if there is clear SAH and significant renal dysfunction in a patient NOT on HD)

• Cerebral Angiography is the gold standard.• If the aneurysm is able to be coiled intravascularly, it will

be done at the time of the angiogram.

Example of CT with Corresponding Angiography

The coiling process with microcatheter

What if it cannot be coiled?

The Titanium Clip!

The Pipeline Stent

Back to the NCCU…what’s next?

Cerebral Edema Phase Days 3-5 post SAH Utilize Hypertonic (3%) Saline to decrease Why not Mannitol?

The Vasospasm Window

Days 4-14 Creates Delayed Ischemic Deficits Responsible for worsening outcomes in 1/3 patients

Monitoring Vasospasm Clinical Symptoms (HA, confusion, focal deficits) Clinical Signs (increasing bp, increasing urinary output,

dropping sodium levels) Studies:

Transcranial Doppler CT Angiography (95% negative predictive value) CT Perfusion Cerebral Angiography EEG with Compressed Spectral Analysis

Preventing (?) Vasospam

Nimodipine 60mg p.o. q 4 hrs for 21 days Euvolemia Normal Magnesium level (2.0 or greater) Avoid hypotension Treat abnormal LDL with statins

Treating Vasospasm (Medical)

• HHH therapy (Hypervolemia, Hypertension, and Hypoviscosity)

• Goal Intake and Output net for every 24 hours should be 1-500cc positive

• Goal SBP 160-220 (may use neosynephrine once a clear euvolemia to slightly hypervolemic state is reached to achieve)

• Goal Hemoglobin is 10

Treating Vasospasm (Surgical)

Intra-arterial injection of Calcium Channel Blockers (here we use verapamil) at the site of vasospasm

Direct Angioplasty (high risk)

What about AEDs?

Use in all aneurysmal SAH until aneurysm secure. If a seizure has occurred, keep AED for 4 weeks If a seizure has occurred and an intraparenchymal

hemorrhage was also present, consider longer treatment than 4 weeks.

Leviteracetam or Phenytoin

What About Hydrocephalus?

Common EVD should be placed in those with radiographic HCP

and high grade SAH Delayed Hydrocephalus (under normal pressure) can

occurred months or even years after SAH due to scarring

What if there is an SAH and a Negative Angiogram? Re-review history….? Occult trauma Thrombosis of ruptured aneurysm Difficult to visualize small aneurysm Spinal AVM Cerebral Venous Thrombosis Vasculitis Benign Perimesencephalic

Negative-Angiogram SAH Words to Never Forget…..

Remember: The Onus is on us to prove that there is no aneurysm. So if one is not seen on the first angiogram and there is no other etiology for the hemorrhage found, repeat the angiogram in 7 days.

Cardiac Effects

Catecholamine induced subendocardial myonecrosis Temporary or permanent reduction in EF Arrythmias (typically tachyarrhythmia unless increased

ICP, then bradyarrhythmias) Flash pulmonary edema

Monitoring and Care

Ideally in a high volume center Institutions with a dedicated Neuro-ICU with

Neuroscience Nurses are preferred and shown to improve outcomes

My reasons to prevent a Stroke

Subarachnoid Hemorrhage Quiz

Thank you for completing this module

Questions? Diana.Greene-Chandos@osumc.edu

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