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CLINICAL AND NEUROIMAGING
STUDIES IN CASES OF
SPONTANEOUS SUBARACHNOID
HAEMORRHAGE
INTRODUCTION
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
Incidence
n/100,000 patients 95% CI
Finland
22.0
USA
12.0
Japan
23.0
New Zealand
14.3
Australia
26.4 ‡
Netherlands
7.8
Iceland
8.0
Greenland Eskimo
9.3
Denmark
3.1
Faeroe Islands
7.4
Indians
4.3
Qatar
5.1
Overall
10.5
‡
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
Aetiology:
 Dural sinus thrombosis &/or AV fistula.
 Spinal AVMs
 Pretruncal non-aneurysmal SAH
 Rarities:
- Tumours
- Cocaine abuse
- Sickle cell disease
- Atrial myxoma
- Pituitary apoplexy
 No cause in 7 – 10%
INTRODUCTION
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

Reflex changes 19%

Motor deficit 17%

Dysphasia 13%

Confusion 12%

Intraocular haemorrhages 12%

Anisocoria 12%
INTRODUCTION
Clinical presentation

Papilloedema 11%

Homonymous hemianopsia 9%

Lateralized headache 8%

Third nerve palsy 7%

Sensory disturbance 5%
INTRODUCTION
Complications

Ischaemic deficits 27%

Hydrocephalus 12%

Brain swelling 12%

Recurrent haemorrhage 11%

Intracranial hematoma 8%

Pneumonia 8%
INTRODUCTION
Complications

Seizures 5%

Gastrointestinal haemorrhage 4%

SIADH 4%

Pulmonary oedema 1%
INTRODUCTION
Investigations
Computed Tomography (CT)

Hydrocephalus 20%

The presence of intraventricular blood (13-28%)

Intraparenchymal blood (20-40%)

Subdural blood (1 - 3%)
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 surgery
Follow 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
INTRODUCTION
Management
General
- Nursing
- Nutrition
- Blood pressure
- Fluid and electrolytes
- Pain
- Prevention of DVT, or pulmonary embolism
INTRODUCTION
Management
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
Vasospasm

Curative treatment:
- Intrathecal sodium nitroprusside
- Nitroglycerine
- Cyclosporin
- Steroids
- Hyperdynamic Therapy (Triple H therapy)
INTRODUCTION
Management
Vasospasm

Curative treatment:
- Barbiturate coma
- Cisternal irrigation
- Gene therapy
- Angioplasty
- Intra-arterial injection of vasodilator
- Intra-aortic counterpulsation
INTRODUCTION
Management
Rebleeding

Antifibrinolytic drugs (TEA, EACA)

Early surgical intervention
INTRODUCTION
Management
Hydrocephalus

Conservative

Repeated LP

Vetriculostomy

Shunt
INTRODUCTION
Management
Systemic complication

Hyponatraemia

Cardiac complications

Pulmonary complications
INTRODUCTION
Management
Endovascular & nonsurgical techniques to treat the
aneurysm

Trapping

Proximal ligation (hunterian ligation)

Thrombosing aneurysm with GDC & Balloon
embolization.
INTRODUCTION
Management
Surgical treatment

Clipping

Wrapping

Coating
AIM OF THE WORK
AIM OF THE WORK
This work is carried out to evaluate the
clinical presentation and various diagnostic
procedures of spontaneous subarachnoid
haemorrhage.
PATIENTS & METHODS
PATIENTS & METHODS
PATIENTS & METHODS
PATIENTS & METHODS
PATIENTS WERE SUBJECTED TO
History taking
Neurological examination
Laboratory investigations
Lumbar puncture
CT scanning & CTA
MRA
MRI FLAIR
4 vessels angiography
PATIENTS & METHODS
Table : Hunt and Hess scale
Grade
Description
I
Asymptomatic or mild headache and slight nuchal rigidity
II
Cr. N. palsy, moderate to severe headache, nuchal rigidity
III
Mild focal deficit, lethargy, or confusion
IV
Stupor, moderate to severe hemiparesis, early decerebrate rigidity
V
Deep coma, decerebrate rigidity, moribund appearance
Modified classification adds the following:
0
Unruptured aneurysm
Ia
No 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
RESULTS
RESULTS
Haemorrhagic stroke
Ischemic stroke
SAH
Number and percentage of stroke patients admitted to the
neurology department in Mansoura Emergency University
Hospital in the period of the study
RESULTS
Female
Sex distribution
Male
RESULTS
Age distribution in males
30 - 39
40 - 49
50 - 59
60 - 69
> 70
RESULTS
30 - 39
40 - 49
50 - 59
60 - 69
Age distribution in females
> 70
RESULTS
20
15
10
5
0
I
II
III
Males
IV
V
Females
Sex distribution in the different grade of
the studied patients
RESULTS
GI
GII
GIII
GIV
GV
Total
100
80
60
No
40
20
%
0
Clinical Grading System according to H & H.
RESULTS
80
60
40
20
0
I
II
Mean
III
IV
SD
V
SE
Mean age in the different grade of the studied
patients
RESULTS
12 AM : 6 AM
12 PM : 6 PM
6 AM : 12 PM
6 PM : 12 AM
percentage of patients according to time of onset of
SAH
0
0
00
00
00
00
10
:0
8:
6:
4:
2:
12
:0
0
00
00
00
00
0
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
8
10
:0
8:
6:
4:
2:
12
:0
RESULTS
No. of patients
7
6
5
4
3
2
1
0
Incidence of SAH in the 24 hours SAH
RESULTS
40
30
20
10
Bleeding
diasthesis
Collagen
vascular
disease
Drug abuse
Family history
Frequency of risk factors
Hyperuricemia
Smoking
Diabetes
mellitus
Dyslipidemia
Hypertension
0
RESULTS
Total
Fourth week
Third week
Second week
First week
No. of
death
%
30 days case fatality rate
RESULTS
TOTAL
DEATH (YES)
The relation between the clinical grades
and mortality rate
I
%wthin GRADE
II
%wthin GRADE
III
%wthin GRADE
IV
%wthin GRADE
V
%wthin GRADE
Total
%wthin GRADE
DEATH (NO)
RESULTS
40
30
20
10
0
%
Rebleeding
Vasospasm
Initial haemorrhage
Others
Causes of short term mortality
RESULTS
100
80
60
40
20
0
%
ASAH
PMH
Negative
CT finding in our series
RESULTS
80
70
60
50
40
30
20
10
0
%
MCA aneurysm
A com A aneurysm
Multiple aneurysms
Vasospasm
No aneurysm
AVM
MRA finding of the examined patients
RESULTS
60
50
40
30
20
10
0
%
MCA aneurysm
A Com A aneurysm
MCA & A Com A aneurysm
PCA aneurysm
ICA 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
CONCLUSIONS
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
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 .
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 .
CONCLUSIONS
Hypertension , smoking , diabetes, age and
dyslipedemia are the main risk factors .
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 .
CONCLUSIONS
CT scanning is mandatory in all , to be followed by
(delayed ) lumber puncture if CT is negative .
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.
RECOMMENDATIONS
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
If the CT scan is negative , lumber puncture may
be helpful if the history of ictal headache is not
typical of subarachnoid haemorrhage
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
Blood pressure must closely monitored and
controlled following SAH . Hypertension will
increase the chance of catastrophic rebleeding .
Blood
pressure
control
should
immediately upon diagnosis of SAH.
be
initiated
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 nonoperatively or neurointerventionally until their
clinical condition improves .
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