Clinical Case

Subarachnoid Hemorrhage

Rifka Nur Annisa

41181396100013

Advisor
Dr. Ahmad Sulaiman Alwahdy, Sp.N. FINA

Neurology Department of RSUP Fatmawati

http://www.free-powerpoint-templates-design.com
Case Presentation
PATIENT MEDICAL DATA

❏ Name : Mr. BW
❏ Age : 54 y.o
❏ Gender : Male
❏ Location : Pamulang, South Tangerang
❏ Job : Farmer
❏ Education : High School
❏ Marital status : Married
❏ Religion : Islam
MEDICAL HISTORY
Chief complaint C

Loss of consciousness at 2 hours before admission

History taking was done by auto-anamnesis on November 14, 2021 in the Teratai ward
MEDICAL HISTORY
Current medical history
The patient fell and his head hit the hard ground and rocks
while in the rice field (swale). The patient then fainted, and blood
came out of his left ear. The patient was then taken to the
Emergency Department Fatmawati Hospital. When in the ED
the patient was conscious and complained of severe headache
VAS 7. There were no seizures, weakness on one side, confusion,
visual disturbances, nausea and vomiting. There are no lucid
intervals.

On the 3rd day of hospitalization during history taking, the

patient still complained of headaches VAS 3-4, and pain in the
left shoulder. No other complaints.
The patient fell and his patient still complained of
head hit the hard ground headaches VAS 3-4, and pain
and rocks Patient was conscious in the left shoulder

2 Hours ED 3rd Day

Loss of consciousness and patient was conscious and

blood came out of left ear complained of severe headache
VAS 7
MEDICAL HISTORY
Past medical history
❑ No history of hypertension, diabetes, and heart disease

❑ No history of stroke
MEDICAL HISTORY
Family medical history

❑ There is no family history of diabetes, hypertension,

heart disease and stroke.
MEDICAL HISTORY
Habit and social history
❑ The patient is a grocer, and also a farmer

❑ He lives with his wife and 2 children

❑ No history of alcohol or narcotics consumption

❑ Patient rarely exercise

PHYSICAL EXAMINATION

Body Weight: 58 kg

Height: 165 cm

BMI: 21.3 kg/m2

Nutritional State: Normoweight

PHYSICAL EXAMINATION
Vital Sign
In ED In Ward
❑ Awareness: Compos mentis ❑ Awareness: Compos mentis
❑ GCS : E4M6V5
❑ GCS : E4M6V5
❑ Blood pressure: 113/79 mmHg
❑ Blood pressure: 134/73 mmHg
❑ Pulse: 67 x/minute, regular,
❑ Pulse: 70 x/minute, regular,
strong palpable, sufficient
strong palpable, adequate
content, pulse deficit (-)
content, pulse deficit (-)
❑ Breathing: 20 x/minute,
❑ Breath: 20 x/minute,
abdominothorax, regular
abdominothorax, regular
❑ Temperature : 36.0 C
❑ Temperature : 36.5 C
REVIEW OF SYSTEM
Head Normocephal, symmetrical face, facial paralysis (-)

Eye Good eye movement in all directions, hyperemic (-), anemic

conjunctiva (-/-), clear cornea, icteric sclera (-/-), pupil round,
3mm, 3mm, isochore, direct and consensual eye reflex (+/+ ).

Ear Normotia, tragus tenderness (-), blood clot in left ear,

hyperemia (-), edema (-).

Nose Nostril breathing (-/-), septal deviation (-), sinus tenderness (-),
inferior and middle nasal cavities were not visible.

Throat Moist lips, uvula in the middle, symmetrical pharyngeal arch,

tonsils T1/T1, detritus (-), crypts (-), normal posterior pharyngeal
wall.

Neck M. sternocleidomastoid retraction (-), JVP 5-2 cmH2O, lymph

nodes are not enlarged, trachea in the middle.
REVIEW OF SYSTEM
Pulmo • I: Lump (-), subcutis emphysema (-), retraction of the intercostal
muscles (-), symmetrical chest movement both static and dynamic
• P: Lump (-), crepitus (-), intercostal space within normal limits,
symmetrical chest expansion, normal fremitus.
• P: Resonance of both lung fields
• A: Vesicular +/+, rhonchi -/-, wheezing -/-.

Heart • I: Ictus cordis not visible

• P: Ictus cordis is palpable at ICS VI midclavicular sinistra
• P: Right heart border at ICS IV parasternal dextra, left heart border at
ICS VI midclavicular sinistra 3 fingers laterally, waistline heart: ICS IV
midcalivicula sinistra 1 finger medially.
• A: regular I-II heart sound, murmur (-), gallop (-)
REVIEW OF SYSTEM
Abdomen • I: Symmetrical movement when static or dynamic
• P: Firm, tenderness (-), liver enlargement (-), spleen enlargement (-)
• P: Tympany the entire abdominal field
• A: Bowel sounds are normal

Extremity
Warm, CRT < 2 seconds, no visible cyanosis, edema (-/-)
NEUROLOGICAL EXAMINATION
GCS : E4M6V5
Pupil : Round, isochore, diameter 3mm/3mm, direct and consensual reflex +/+

Meningeal sign

Right Left
Neck stiffnes (+)
Laseque > 70o > 70o
Kernig > 135o > 135o
Brudzinski I (-) (-)
Brudzinski II (-) (-)
NEUROLOGICAL EXAMINATION
Cranial Nerve

N. I
Normosmia / Normosmia

N. II

Right Left
Vision 3/60 confined space 3/60 confined space
Field of vision Good Good
Fundoscopy Not implemented Not implemented
NEUROLOGICAL EXAMINATION
Cranial Nerve

N. III, IV, VI

Right Left
Eyeball position Ortoforia Ortoforia

Eyeball movement

M. levator palpebra Ptosis (-) Ptosis (-)

Exophtalmos (-) (-)
Nistagmus (-) (-)
Accomodation (+) (+)
NEUROLOGICAL EXAMINATION
Cranial Nerve

N. V

Right Left
Motoric branch
M. Maseter Good Good
M. Temporalis Good Good
M. Pterygoid lateralis Good Good
Sensoric branch
Opthalmica Good Good

Maxilla Good Good

Mandibularis Good Good

NEUROLOGICAL EXAMINATION
Cranial Nerve

N. VII

Right Left
M. Frontalis Symmetrical Symmetrical
M. Orbicularis oculi Symmetrical Symmetrical
M. Buccinator Symmetrical Symmetrical
M. Orbicularis oris Symmetrical Symmetrical
Taste buds Not implemented Not implemented
NEUROLOGICAL EXAMINATION
Cranial Nerve

N. VIII
Right Left
Vertigo (-)
Nistagmus (-)
Rhine Not implemented Not implemented
Weber Not implemented Not implemented
Swabach Not implemented Not implemented
NEUROLOGICAL EXAMINATION
Cranial Nerve

N. IX, X

Uvula : uvula in the middle, no deviation

Pharyngeal arch : lifting strength, symmetrical right and left, no deviation
Palatum Mole : symmetrical right and left
Gag Reflex : (+)
NEUROLOGICAL EXAMINATION
Cranial Nerve
N. XI Right Left
M. Trapezius Good Good
M. Sternocleidomastoideus Good Good

N. XII
Static : Symmetrical
Pergerakan Lidah : Symmetrical
Atrofi : (-)
Fasikulasi : (-)
Tremor : (-)
NEUROLOGICAL EXAMINATION

Motoric Function

Trophy : Eutrofi/Eutrofi
Tone : Normotone
Motor strength :
5555 5555
5555 5555
Physiological Reflexes
Right Left
Biceps +2 +2
Triceps +2 +2
Patella +2 +2
Achilles +2 +2
NEUROLOGICAL EXAMINATION
Pathological Reflexes

Right Left
Hoffman Tromner (-) (-)
Babinsky (-) (-)
Chaddock (-) (-)
Gordon (-) (-)
Gonda (-) (-)
Schaeffer (-) (-)
Klonus Lutut (-) (-)
Klonus Tumit (-) (-)
NEUROLOGICAL EXAMINATION

Sensorics Function
Proprioceptive : Good

Exteroceptive : Good

Autonomic Function
Urinate : Good

Defecation : Good

Perspiration : Normohidrosis
SUPPORTING INVESTIGATION
Head CT: November 5, 2021
SUPPORTING INVESTIGATION
Head CT: November 5, 2021
SUPPORTING INVESTIGATION
Head CT: November 5, 2021

• Subarachnoid hemorrhage in the right

temporal region

• No fracture of the calvarial bones

• Left chronic otomastoiditis

• Bilateral maxillary sinus retention cysts

SUPPORTING INVESTIGATION
Brain MRI and MRA: November 10, 2021

• Right temporal lobe focal cortical hemorrhage, size 1.1 x 0.8 cm

• Sphenoid hemato-sinus

• Right temporo-occipital subdural hemorrhage

• Bilateral maxillary sinus retention cyst

• Left mastoiditis
SUPPORTING INVESTIGATION
Laboratory result: November 5, 2021

Result References
Hematology
Hemoglobin 12.7 g/dl 13,2 – 17,3 g/dl
Hematocrit 37.3% 40 – 52%
Leukocytes 9,200/ul 5 – 10 thousand/ul
Platelet 210,000/ul 150–440 thousand/ul
Erythrocytes 4.04 million/ ul 4.40 – 5.90 million/ul

VER 91.3 fl 80.0 – 100.0 fl

HER 31.1 pg 26.0 – 34.0 pg
KHER 34.1 g/dl 32.0 – 36.0 mmol/L
RDW 13.8 % 11.5 – 14.5 %
Diff Count 0/2/78/13/2
Absolute lymphocyte 1,201/ul > = 1.500
Neutrophile lymphocyte ratio 5.9
SUPPORTING INVESTIGATION
Laboratory result: November 5, 2021

Result References
Hemostasis
APTT 31.2 seconds 28.6 – 42.2 seconds
APTT control 36.2 seconds
PT 11.4 seconds 11.7 – 15.1 seconds
PT control 15.7 seconds
INR 0.8
Fibrinogen 340 mg/dl 200 – 400 mg/dl
D-Dimer 10,692 ng/ml <= 500
Liver Enzyme
SGOT 21 U/I 0 – 40 U/I
SGPT 15 U/I 0 – 41 U/I
SUPPORTING INVESTIGATION
Laboratory result: November 5, 2021

Result References
Renal Function
Urea 27.2 mg/dl 16.6 – 48.5 mg/dl
Creatinine 0.98 mg/dl 0,6 7– 1,17 mg/dl
Electrolyte
Sodium 137 mmol/l 135 – 147 mmol/l
Potassium 3.4 mmol/l 3.50 – 5.10 mmol/l
Chloride 101 mmol/l 98 – 107 mmol/l
Random blood glucose 110 mg/dl 70 -140 mg/dl
SUPPORTING INVESTIGATION
Chest X-ray: November 5, 2021

• No radiological abnormalities were seen in

the heart and lungs

• Left glenoid anterior comminuted fracture

SUMMARY
Mr. BW, 49 years, was brought to the Emergency Department Fatmawati Hospital,
loss of consciousness at 2 hours before admission after fell and his head hit the
hard ground and rocks while in the rice field (swale). When in the ED the patient
was conscious and complained of severe headache VAS 7. There were no seizures,
weakness on one side, confusion, visual disturbances, nausea and vomiting.. On
the third day of hospitalization during history taking, the patient still complained
of headaches VAS 3-4, and pain in the left shoulder. No other complaints. No
history of hypertension, diabetes, and heart disease. No history of stroke
SUMMARY
On physical examination in the emergency room, blood pressure was found at
113/79 mmHg, pulse 67x/minute, regular, strong palpable, adequate contents,
breath 20x/minute abdominal-thoracic, regular, and temperature 36.0ºC. Vital
signs in the ward BP 134/73 mmHg, pulse 70x/minute, regular, strong palpable,
adequate contents, breath 20x/minute abdominal-thoracic, regular, and
temperature 36.5ºC. Generalist status examination within normal limits.
Examination of neurological status: GCS E4M6V5. Meningeal sign neck stiffness
positive Cranial nerve were normal, normal physiological reflexes, no pathological
reflexes

On laboratory examination, complete blood count (12.7/37.3/9.2/210/4.04),

differential count (0/2/78/13/2), absolute lymphocyte 1,201/ul, neutrophile
lymphocyte ratio 5.9, electrolyte sodium 137, potassium, chloride 3.4/101.
SUMMARY
On examination, a chest X-ray revealed that no radiological abnormalities of
heart and lungs. Left glenoid anterior comminute fracture. On CT scan of the
head the impression of Subarachnoid hemorrhage in the right temporal
region, No fracture of the calvarial bones. On brain MRI, Right temporal lobe
focal cortical hemorrhage, size 1.1 x 0.8 cm, Sphenoid hemato-sinus, Right
temporo-occipital subdural hemorrhage
DIAGNOSIS
Clinical Diagnosis:
- Loss of consciousness
- Secondary headache
- Shoulder pain

Topical Diagnosis: Right temporal subarachnoid, cerebrum

Etiological Diagnosis: Subarachnoid vascular rupture

Pathological Diagnosis: Bleeding

Working Diagnosis:
- Subarachnoid hemorrhage
- Cerebral contusion
- Close fracture of left glenoid
TREATMENT
Medicine

o Nimodipin 4 x 60 mg
o Laxative 3 x 10 cc
o Amlodipin 1 x 10 mg
o KSR 3 x 1
o Simvastatin 1 x 10 mg
o Mannitol 4 x 125 cc
o Pantoprazol 1 x 40 mg
o Paracetamol 3 x 1 gr
o Eterocoxib 1 x 90 mg
TREATMENT
Non-medical

• Monitor for signs of increased ICP (headache, loss of consciousness,

vomiting, seizures)
• Monitor blood pressure, pulse, respiration, temperature and oxygen
saturation
• O2 NRM 2-4 lpm
• Enteral nutrition 1500 kcal/day
• Education related to disease, treatment plans, and disease prognosis
• Refer to Orthopedic Department for Close Fracture
• Refer to Interna Department for hypercoagulation
PROGNOSIS
Ad Vitam : Dubia Ad Bonam

Ad Functionam : Bonam

Ad Sanationam : Bonam
Discussion
 INTRODUCTION
Intracranial hemorrhage is the bleeding inside the brain
parenchyma that may occur spontaneously or by an insult like
trauma.
Intracranial hemorrhage (ICH) is a devastating that may be
spontaneous or due to a traumatic event.

It is a life-threatening condition and a great cause of mortality

and morbidity common in the adult population compared to the
children

Intracranial hemorrhage encompasses four broad types of

hemorrhage: epidural hemorrhage, subdural hemorrhage,
subarachnoid hemorrhage, and intraparenchymal hemorrhage.

García-Ballestas E, Durango-Espinosa Y, Mendoza-Flórez R, et al. The puzzle of spontaneous versus traumatic subarachnoid hemorrhage. Apollo Medicine. 2019;16(3):141.
Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
 SUBARACHNOID HEMORRHAGE
The term subarachnoid hemorrhage (SAH) refers to
extravasation of blood into the subarachnoid space between the
pial and arachnoid membranes

Typically the superficial sulci along the cerebral convexities

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kim J, Lee SJ. Traumatic subarachnoid hemorrhage resulting from posterior communicating artery rupture. International Medical Case Reports Journal. 2020;13:237-241.
 ETIOLOGY
Although head trauma causes some cases of SAH, up to 85% is
the result of a ruptured saccular aneurysm (berry aneurysm).
These aneurysms often occur within the Circle of Willis and its
branches.
Acquired factors thought to be associated with aneurysmal
formation include the following:
- Atherosclerosis
- Hypertension
- Advancing age
- Smoking
- Hemodynamic stress

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
 ETIOLOGY
Other causes of subarachnoid hemorrhage include
arteriovenous malformations (AVM), use of blood thinners,
trauma, or idiopathic causes.

Other precipitators of a SAH include:

- cocaine abuse,
- sickle cell anemia,
- anticoagulation disorders, and
- dissection of a vertebral artery.

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
 CLASSIFICATION

- Subarachnoid hemorrhage is divided into traumatic versus

non-traumatic subarachnoid hemorrhage.

- A second categorization scheme divides subarachnoid

hemorrhage into an aneurysmal and non-aneurysmal
subarachnoid hemorrhage.

Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 CLASSIFICATION
- Aneurysmal subarachnoid hemorrhage occurs after the
rupture of a cerebral aneurysm allowing for bleeding into the
subarachnoid space.

- Non-aneurysmal subarachnoid hemorrhage is bleeding into

the subarachnoid space without identifiable aneurysms.

- Nonaneurysmal subarachnoid hemorrhage most commonly

occurs after trauma with a blunt head injury with or without
penetrating trauma or sudden acceleration changes to the
head.

Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 EPIDEMIOLOGY
- Intracranial hemorrhage is a common disease with an
approximate incidence of 25 per 100,000 persons every year

- Spontaneous SAH happens in about one per 10,000 people per

year.

- Females are more commonly affected than males. (1.15 : 1)

- Although this clinical entity is more common with older age,

about 55% of patients with an SAH present under age 55.

- Up to 10% of patients with a SAH report a history of bending over,

lifting heavy objects, or performing other strenuous activities, at
the onset of their symptoms.

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
 PATOPHYSIOLOGY
- Subarachnoid hemorrhage most commonly occurs after
trauma where cortical surface vessels are injured and bleed
into the subarachnoid space.

- Traumatic SAH usually occurs near the site of a skull fracture

and intracerebral contusion.

- Radiologic clues of a traumatic origin include localized

bleeding in a superficial sulcus, an adjacent skull fracture, and
a cerebral contusion with external evidence of traumatic
injury

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 PATOPHYSIOLOGY
- Non-traumatic subarachnoid hemorrhage is most commonly
due to the rupture of a cerebral aneurysm. When aneurysm
ruptures, blood can flow into the subarachnoid space.

- Aneurysms are acquired lesions related to hemodynamic

stress on the arterial walls at bifurcation points and bends.

- These intracranial aneurysms are thin-walled protrusions from

an intracranial artery that often has a thin (or absent) tunica
media as well as an absent internal elastic lamina.

- Often hemodynamic stress leads to excessive wear on the wall

of these arteries leading to turbulent blood flow within the
vessel, which causes structural fatigue and aneurysm
development.

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 HISTORY TAKING
Patients may report a history of a head injury before the onset
of symptoms or a known history of a cerebral aneurysm.

Other risk factors include high blood pressure, smoking, family

history, and drug/alcohol abuse

Patients may also report having a history of a prior severe

headache and/or a history of a small bleed with resolving
symptoms within the past month.

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
 SYMPTOM
A thunderclap headache (sudden severe headache or worst
headache of life) is the classic presentation of subarachnoid
hemorrhage.

Other symptoms include:

- dizziness,
- nausea,
- vomiting,
- diplopia,
- seizures,
- loss of consciousness, or
- nuchal rigidity

Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 SIGN
Physical exam findings may include:

- focal neurologic deficits,

- cranial nerve palsies,

(oculomotor abnormality/palsy, which may
indicate the posterior communicating artery as
the source of the bleed.)

- nuchal rigidity,
(there is meningeal irritation from the SAH)

- decreased or altered consciousness.

Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
 EVALUATION - RADIOLOGY
The diagnosis of subarachnoid hemorrhage (SAH) usually
depends on a high index of clinical suspicion combined with
radiologic confirmation via urgent computed tomography (CT)
scan without contrast.

Generally, if a non-contrast head CT is obtained within 6 hours

of symptom onset, the diagnosis can be determined based on
this imaging.

Non-contrast CT followed by CT angiography (CTA) of the brain can

rule out SAH with greater than 99% sensitivity. It can be used to identify
an aneurysmal source of the bleed.

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 EVALUATION - RADIOLOGY
If the non-contrast head CT is indeterminate, or if the patient
presents outside of the 6-hour window, a lumbar puncture (LP)
should be discussed with patients

Lumbar puncture has been found in some studies to show

evidence of hemorrhage in 3% of patients with a normal head
CT

Conversely, a recent study concluded that LP, in their cohort of

neurologically intact CT-negative emergency department
headache patients, did not identify any cases of aneurysmal
SAH

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2021 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 EVALUATION - RADIOLOGY

Stellata (star sign)

Brain CT scan showing subtle finding of blood at CT scan reveals subarachnoid hemorrhage in the
the area of the circle of Willis consistent with acute right sylvian fissure; no evidence of
subarachnoid hemorrhage. hydrocephalus is apparent

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 EVALUATION - RADIOLOGY

Cerebral angiogram reveals a middle cerebral Cerebral angiogram (lateral view) reveals a large
artery aneurysm. aneurysm arising from the left anterior choroidal
artery.

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 EVALUATION - LABORATORY
✓ Serum chemistry panel - To establish a baseline for detection
of future complications

✓ Complete blood count - For evaluation of possible infection or

hematologic abnormality

✓ Prothrombin time (PT) and activated partial thromboplastin

time (aPTT) - For evaluation of possible coagulopathy

✓ Blood typing/screening - To prepare for possible intraoperative

transfusions

✓ Cardiac enzymes - For evaluation of possible myocardial

ischemia

✓ Arterial blood gas (ABG) - Necessary in patients with

pulmonary compromis

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 EVALUATION - LABORATORY
✓ Consistently elevated red blood cell counts in all cerebrospinal
fluid (CSF) tubes may indicate a SAH.

✓ Additionally, the presence of bilirubin within the CSF may also

indicate a SAH; this method can only reliably detect a SAH 12
hours after its onset

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 CLINICAL SEVERITY SCALES
Clinical assessment of SAH severity commonly utilizes grading
scales.

The 2 clinical scales most often employed are the Hunt and Hess
and the World Federation of Neurological Surgeons (WFNS)
grading systems.

A third, the Fisher scale, classifies SAH based on CT scan

appearance and quantification of subarachnoid blood.

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 CLINICAL SEVERITY SCALES
In 1968, Hunt and Hess established a SAH severity
scale based on symptoms at presentation.

• Grade 0 - Unruptured aneurysm

• Grade I - Asymptomatic or mild headache and slight nuchal rigidity
• Grade Ia - Fixed neurological deficit without acute meningeal/brain
reaction
• Grade II - Cranial nerve palsy, moderate to severe headache, nuchal
rigidity
• Grade III - Mild focal deficit, lethargy, or confusion
• Grade IV - Stupor, moderate to severe hemiparesis, early decerebrate
rigidity
• Grade V - Deep coma, decerebrate rigidity, moribund appearance

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 CLINICAL SEVERITY SCALES
The Fisher Grade was later created in 1980 to classify the
appearance of the SAH based on the appearance of the CT scan.

• Group 1 - No blood detected

• Group 2 - Diffuse deposition of subarachnoid blood, no clots, and no
layers of blood greater than 1 mm
• Group 3 - Localized clots and/or vertical layers of blood 1 mm or greater
in thickness
• Group 4 - Diffuse or no subarachnoid blood, but intracerebral or
intraventricular clots are present

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 CLINICAL SEVERITY SCALES
In 1988, the World Federation of Neurosurgeons classification was
developed to include the patient’s Glasgow coma score (GCS) and focal
neurological deficits to gauge symptom severity.

• Grade 1 - Glasgow Coma Score (GCS) of 15, motor deficit absent

• Grade 2 - GCS of 13-14, motor deficit absent
• Grade 3 - GCS of 13-14, motor deficit present
• Grade 4 - GCS of 7-12, motor deficit absent or present
• Grade 5 - GCS of 3-6, motor deficit absent or present

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 MANAGEMENT
▪ Initial evaluation includes assessing and stabilizing the airway,
breathing, and circulation (ABCs). Patients with subarachnoid
hemorrhage can rapidly deteriorate and may need emergent
intubation.

▪ Endotracheal intubation should be performed for patients

presenting with coma, depressed level of consciousness,
inability to protect their airway, or increased intracranial
pressure (ICP).

▪ Rapid-sequence intubation should be employed, if possible,

including the use of sedation, defasciculation, short-acting
neuromuscular blockade, and agents to blunt an increase in
ICP.

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 MANAGEMENT
▪ Intravenous access should be obtained, including central and
arterial lines.

▪ A short-acting benzodiazepine, such as midazolam, should be

administered prior to all procedures.

▪ Monitoring should include the following:

▪ Cardiac monitoring
▪ Pulse oximetry
▪ Automated and/or arterial blood pressure monitoring
▪ End-tidal carbon dioxide, if applicable
▪ Urine output via placement of a Foley catheter

▪ A thorough neurologic examination can help identify any

neurologic deficits.

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 TREATMENT
▪ Once the diagnosis of a SAH is made, most patients will be
admitted to a neurosurgical intensive care unit.

▪ An external ventricular drain (EVD) may be indicated if the

patient has a poor clinical grade on admission, acute
neurological deterioration, or progressive ventricular
enlargement on CT.

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 TREATMENT
▪ Patients with a large hematoma, decreased level of
consciousness, or any focal neurological deficits may require
surgical removal of the blood and/or occlusion of the bleeding
site.

▪ If a cerebral aneurysm is identified on angiography, clipping or

coiling can be used to reduce the risk of further bleeding.

▪ Clipping requires a craniotomy to visualize and place clips

around the neck of the aneurysm.

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 TREATMENT
▪ Calcium channel blockers such as nimodipine or nicardipine
are often used to prevent vasospasm.

▪ Vasospasm can lead to ischemic brain injury (delayed

ischemia) as a result of the restricted blood flow caused by
vessel constriction.

▪ Nimodipine has been shown to improve patient outcomes if

given between the fourth and twenty-first day after bleeding
from an aneurysmal SAH.

▪ Nimodipine has not been shown to affect long-term outcomes

in traumatic SAH and is therefore not recommended in these
cases.

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
 COMPLICATION

▪ Hydrocephalus
▪ Rebleeding
▪ Vasospasm
▪ Seizures
▪ Cardiac dysfunction

Becske T, Lutsep HL. Medscape. Subarachnoid Hemorrhage. 2018

 PROGNOSIS

▪ SAH is often associated with a poor outcome.

▪ Nearly half of patients presenting with a SAH caused by an
underlying aneurysm die within 30 days, and a third of those
who survive have complications.
▪ Roughly half of the patients who have had a SAH suffer from
some neurocognitive impairment that impacts their quality of
life.
▪ Over 60% report ongoing and recurring headaches.

Kairys N, M Das J, Garg M. Acute Subarachnoid Hemorrhage. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
THANK YOU
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