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Subarachnoid Haemorrhage

Title               

Ñ    Subarachnoid Haemorrhage

Definition

Ñ    Spontaneous arterial bleeding into the subarachnoid space

Pathogenesis

Underlying causes

Internal Factors

Ñ    Bleeding disorders

Mural Factors

Ñ    Saccular (berry) aneurysm

Ñ    Arteriovenous malformation  (AVM)

Ñ    Mycotic aneurysm:

Infective endocarditis

Ñ    Arteritis

External Factors

Ñ    Brain tumours

Ñ    Bacterial meningitis

Systemic factors

CVS

Ñ    Coarctation of the aorta

LMS

Ñ    Marfan’s syndrome

IS

Ñ    Ehlers-Danlos syndrome

KUS

Ñ    Polycystic kidneys

Pathological Process

Ñ    Sudden arterial haemorrhage into the subarachnoid space

Clinical Features

History

CNS

Ñ    Sudden onset of severe headache:

Usually occipital

Examination

CNS

Ñ    Decreased level of consciousness

Ñ    Papilloedema

Ñ    Retinal haemorrhage

Ñ    Subhyaloid haemorrhage

Ñ    Neck stiffness

Ñ    Kernig’s sign

Complications

CNS

Ñ    Obstructive hydrocephalus

Ñ    Severe arterial spasm

Investigations

Fluids

Cerebrospinal Fluid

Haematology

Ñ    Red cells in CSF

Biochemistry

Ñ    Xanthochromia:

Appears after several hours

Ñ    Bilirubin (from lysed red cells):

Detected using spectrophotometry

Imaging

CT Scan

Ñ    Subarachnoid, intraventricular blood

MRI

Ñ    MR angiogram:

If potential for surgery

Demonstrates aneurysm or AVM

Management

Control

Surgery            

Aneurysm

Ñ    Clip

Ñ    Coil:

Radiological placement

AVM

Ñ    Surgery

Ñ    Embolism

Radiotherapy

AVM

Ñ    Focal radiotherapy:

Gamma knife

Support

Drugs

Ñ    Antihypertensives:

Control blood pressure

Ñ    Dexamethasone:

Reduce cerebral oedema

Stabilise blood brain barrier

Ñ    Nimlodipine:

Prevent arterial spasm

Prognosis

Ñ    Poor in those who remain comatose or who have persistent deficits

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