Subarachnoid hemorrhage natural history, complications and prognosis: Difference between revisions

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{{Subarachnoid hemorrhage}}
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{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; {{SaraM}}
 
== Overview ==
 
==Natural history==
Following rupture of an [[aneurysm]], the blood directly release into the [[cerebrospinal fluid|cerebrospinal fluid (CSF]]) under [[arterial pressure]]. As the blood spreads quickly into the [[CSF]], it rapidly increasing [[intracranial pressure]].<ref name="pmid23289820">{{cite journal| author=Schuss P, Konczalla J, Platz J, Vatter H, Seifert V, Güresir E| title=Aneurysm-related subarachnoid hemorrhage and acute subdural hematoma: single-center series and systematic review. | journal=J Neurosurg | year= 2013 | volume= 118 | issue= 5 | pages= 984-90 | pmid=23289820 | doi=10.3171/2012.11.JNS121435 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23289820  }} </ref>  Increased intracranial pressure (ICP) occurs secondary to the following factors, including:<ref name="pmid5026540">{{cite journal| author=Nornes H, Magnaes B| title=Intracranial pressure in patients with ruptured saccular aneurysm. | journal=J Neurosurg | year= 1972 | volume= 36 | issue= 5 | pages= 537-47 | pmid=5026540 | doi=10.3171/jns.1972.36.5.0537 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5026540  }} </ref>
* Hemorrhage volume
* Acute hydrocephalus
* [[Hyperemia|Reactive hyperemia]] after [[hemorrhage]]/ [[ischemia]]
* Distal cerebral arteriolar vasodilation
Depending on the location of the [[aneurysm]], the blood can spread into:
*[[Intraventricular|Intraventricular space]]
*Brain parenchyma
*[[Subdural space]]
The bleeding usually lasts only a few seconds. However, rebleeding can be considered as one of the complication which can occur within the first day.<ref name="pmid23117495">{{cite journal| author=Biesbroek JM, van der Sprenkel JW, Algra A, Rinkel GJ| title=Prognosis of acute subdural haematoma from intracranial aneurysm rupture. | journal=J Neurol Neurosurg Psychiatry | year= 2013 | volume= 84 | issue= 3 | pages= 254-7 | pmid=23117495 | doi=10.1136/jnnp-2011-302139 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23117495  }} </ref>
 
Independent predictors of rebleeding after subarachnoid hemorrhage may include:<ref name="pmid19164800">{{cite journal| author=Bederson JB, Connolly ES, Batjer HH, Dacey RG, Dion JE, Diringer MN et al.| title=Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. | journal=Stroke | year= 2009 | volume= 40 | issue= 3 | pages= 994-1025 | pmid=19164800 | doi=10.1161/STROKEAHA.108.191395 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19164800  }} </ref><ref name="pmid22170890">{{cite journal| author=Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K et al.| title=Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. | journal=Neurology | year= 2012 | volume= 78 | issue= 1 | pages= 31-7 | pmid=22170890 | doi=10.1212/WNL.0b013e31823ed0a4 | pmc=3466499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22170890  }} </ref><ref name="pmid3603360">{{cite journal| author=Inagawa T, Kamiya K, Ogasawara H, Yano T| title=Rebleeding of ruptured intracranial aneurysms in the acute stage. | journal=Surg Neurol | year= 1987 | volume= 28 | issue= 2 | pages= 93-9 | pmid=3603360 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3603360  }}</ref>
* [[Aneurysm]] size
 
* The Hunt-Hess grade on admission
* High bleeding pressure
* Presence of sentinel headache prior to SAH
* Early [[ventriculostomy]]
* High blood pressure prior to event
The [[vasospasm]] usually occurs following subarachnoid hemorrhage and typically begins no earlier than day three after hemorrhage and peak at days seven to eight.
it is thought that the blood clots release a spasmogenic substances following blot clots lysis which can result in vasospasm. The vasospasm can lead to [[ischemia]] of the brain which is usually characterized as a single [[Infarct|cortical infarcts]] near the site of the ruptured aneurysm in most case. [[ischemia]] of the brain usually results in neurologic deterioration in level of consciousness or new focal neurologic deficits.<ref name="pmid8450326" /><ref name="pmid572002">{{cite journal| author=Weisberg LA| title=Computed tomography in aneurysmal subarachnoid hemorrhage. | journal=Neurology | year= 1979 | volume= 29 | issue= 6 | pages= 802-8 | pmid=572002 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=572002  }} </ref>
 
Risk factors for developing [[vasospasm]] may include:<ref name="pmid6682190">{{cite journal| author=Kistler JP, Crowell RM, Davis KR, Heros R, Ojemann RG, Zervas T et al.| title=The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study. | journal=Neurology | year= 1983 | volume= 33 | issue= 4 | pages= 424-36 | pmid=6682190 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6682190  }} </ref><ref name="pmid16003069">{{cite journal| author=Badjatia N, Topcuoglu MA, Buonanno FS, Smith EE, Nogueira RG, Rordorf GA et al.| title=Relationship between hyperglycemia and symptomatic vasospasm after subarachnoid hemorrhage. | journal=Crit Care Med | year= 2005 | volume= 33 | issue= 7 | pages= 1603-9; quiz 1623 | pmid=16003069 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16003069  }} </ref> <ref name="pmid21257823">{{cite journal| author=Ko SB, Choi HA, Carpenter AM, Helbok R, Schmidt JM, Badjatia N et al.| title=Quantitative analysis of hemorrhage volume for predicting delayed cerebral ischemia after subarachnoid hemorrhage. | journal=Stroke | year= 2011 | volume= 42 | issue= 3 | pages= 669-74 | pmid=21257823 | doi=10.1161/STROKEAHA.110.600775 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21257823  }} </ref><ref name="pmid10390314">{{cite journal| author=Charpentier C, Audibert G, Guillemin F, Civit T, Ducrocq X, Bracard S et al.| title=Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. | journal=Stroke | year= 1999 | volume= 30 | issue= 7 | pages= 1402-8 | pmid=10390314 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10390314  }} </ref>
* Severe bleeding
* Bleeding the major intracerebral blood vessels
* Age less than 50 years
* [[Hyperglycemia]] 
 
==Complications==
==Complications==
Complications of SAH can be acute, subacute, or chronic.
Complications of SAH can be acute, subacute, or chronic.
* Acute:
* Acute:<ref name="pmid221708903">{{cite journal| author=Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K et al.| title=Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. | journal=Neurology | year= 2012 | volume= 78 | issue= 1 | pages= 31-7 | pmid=22170890 | doi=10.1212/WNL.0b013e31823ed0a4 | pmc=3466499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22170890  }}</ref><ref name="pmid2742543">{{cite journal| author=Graff-Radford NR, Torner J, Adams HP, Kassell NF| title=Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study. | journal=Arch Neurol | year= 1989 | volume= 46 | issue= 7 | pages= 744-52 | pmid=2742543 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2742543  }} </ref>
** [[Coma]] and [[Brain herniation|brainstem herniation]] due to increased [[intracranial pressure]] (ICP)
** [[Coma]] and [[Brain herniation|brainstem herniation]] due to increased [[intracranial pressure]] (ICP)
** Rebleeding
** [[Pulmonary edema]] ("neurogenic pulmonary edema") as a result of the suddenly increased ICP
** [[Pulmonary edema]] ("neurogenic pulmonary edema") as a result of the suddenly increased ICP
** [[Cardiac arrhythmia]]s and [[myocardial]] damage
** [[Cardiac arrhythmia]]s and [[myocardial]] damage
** [[Hydrocephalus]], which may also happen in the subacute time frame
** [[Hydrocephalus]], which may also happen in the subacute time frame
* Subacute:
* Subacute:<ref name="pmid8450326">{{cite journal| author=Haley EC, Kassell NF, Torner JC| title=A randomized controlled trial of high-dose intravenous nicardipine in aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study. | journal=J Neurosurg | year= 1993 | volume= 78 | issue= 4 | pages= 537-47 | pmid=8450326 | doi=10.3171/jns.1993.78.4.0537 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8450326  }}</ref><ref name="pmid572002">{{cite journal| author=Weisberg LA| title=Computed tomography in aneurysmal subarachnoid hemorrhage. | journal=Neurology | year= 1979 | volume= 29 | issue= 6 | pages= 802-8 | pmid=572002 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=572002  }} </ref><ref name="pmid6682190">{{cite journal| author=Kistler JP, Crowell RM, Davis KR, Heros R, Ojemann RG, Zervas T et al.| title=The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study. | journal=Neurology | year= 1983 | volume= 33 | issue= 4 | pages= 424-36 | pmid=6682190 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6682190  }} </ref>
** [[Vasospasm]], leading to [[ischemia]] of the brain
** [[Vasospasm]], leading to [[ischemia]] of the brain
** [[Hyponatremia]] (low [[sodium]] levels) - due to [[SIADH]] or [[cerebral salt wasting syndrome]]
** [[Hyponatremia]] (low [[sodium]] levels) - due to [[SIADH]] or [[cerebral salt wasting syndrome]]
Line 19: Line 52:
** SAH recurrence (20% within two weeks if the aneurysm is not secured by clipping or coiling)
** SAH recurrence (20% within two weeks if the aneurysm is not secured by clipping or coiling)
** Persistent neurologic deficits
** Persistent neurologic deficits
==Prognosis==
==Prognosis==
Nearly half the cases of SAH are either dead or moribund before they reach a hospital. Of the remainder, a further 10-20% die in the early weeks in hospital from rebleeding. Delay in diagnosis of minor SAH without coma (or mistaking the sudden headache for [[migraine]]) contributes to this mortality. Patients who remain comatose or with persistent severe deficits have a poor prognosis.
Nearly half the cases of SAH are either dead or moribund before they reach a hospital. Of the remainder, a further 10-20% die in the early weeks in hospital from rebleeding. Delay in diagnosis of minor SAH without coma (or mistaking the sudden headache for [[migraine]]) contributes to this mortality. Patients who remain comatose or with persistent severe deficits have a poor prognosis.<ref name="pmid23117495">{{cite journal| author=Biesbroek JM, van der Sprenkel JW, Algra A, Rinkel GJ| title=Prognosis of acute subdural haematoma from intracranial aneurysm rupture. | journal=J Neurol Neurosurg Psychiatry | year= 2013 | volume= 84 | issue= 3 | pages= 254-7 | pmid=23117495 | doi=10.1136/jnnp-2011-302139 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23117495  }}
</ref>
 
Following conditions associated with poorer outcome:<ref name="pmid14966173">{{cite journal| author=McCarron MO, Alberts MJ, McCarron P| title=A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage. | journal=J Neurol Neurosurg Psychiatry | year= 2004 | volume= 75 | issue= 3 | pages= 491-3 | pmid=14966173 | doi= | pmc=1738971 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14966173  }} </ref><ref name="pmid11087774">{{cite journal| author=Butzkueven H, Evans AH, Pitman A, Leopold C, Jolley DJ, Kaye AH et al.| title=Onset seizures independently predict poor outcome after subarachnoid hemorrhage. | journal=Neurology | year= 2000 | volume= 55 | issue= 9 | pages= 1315-20 | pmid=11087774 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11087774  }} </ref><ref name="pmid221708902">{{cite journal| author=Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K et al.| title=Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. | journal=Neurology | year= 2012 | volume= 78 | issue= 1 | pages= 31-7 | pmid=22170890 | doi=10.1212/WNL.0b013e31823ed0a4 | pmc=3466499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22170890  }}</ref><ref name="pmid5090970">{{cite journal| author=Herrer A| title=Leishmania hertigi sp. n., from the tropical porcupine, Coendou rothschildi Thomas. | journal=J Parasitol | year= 1971 | volume= 57 | issue= 3 | pages= 626-9 | pmid=5090970 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5090970  }} </ref><ref name="pmid19461033">{{cite journal| author=Zacharia BE, Ducruet AF, Hickman ZL, Grobelny BT, Fernandez L, Schmidt JM et al.| title=Renal dysfunction as an independent predictor of outcome after aneurysmal subarachnoid hemorrhage: a single-center cohort study. | journal=Stroke | year= 2009 | volume= 40 | issue= 7 | pages= 2375-81 | pmid=19461033 | doi=10.1161/STROKEAHA.108.545210 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19461033  }} </ref><ref name="pmid20380973">{{cite journal| author=Wartenberg KE, Mayer SA| title=Medical complications after subarachnoid hemorrhage. | journal=Neurosurg Clin N Am | year= 2010 | volume= 21 | issue= 2 | pages= 325-38 | pmid=20380973 | doi=10.1016/j.nec.2009.10.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20380973  }} </ref>
*[[Seizures]] occur during the first 24 hours
*The combination of subarachnoid hemorrhage with [[Terson's syndrome|preretinal hemorrhages (Terson's syndrome]])
*Rebleeding
*[[Renal dysfunction]]
*[[Fever]]
*[[Anemia]]
*[[Hypoxemia]]
*[[Metabolic acidosis]]
*[[Hyperglycemia]]
*Low or high blood pressure  (MAP <70 or MAP >130 mmHg)
 
===Grading scales===
There are several grading scales available for subarachnoid hemorrhage. These have been derived by retrospectively matching characteristics of patients with their outcomes. In addition to the ubiquitously used [[Glasgow Coma Scale]], three other specialized scores are in use.<ref>{{cite journal |author=Rosen D, Macdonald R |title=Subarachnoid hemorrhage grading scales: a systematic review |journal=Neurocrit Care |volume=2 |issue=2 |pages=110-8 |year=2005 |pmid=16159052}}</ref><ref name=Rosen>Rosen, David S., and R. Loch Macdonald. "Subarachnoid hemorrhage grading scales." Neurocritical care 2.2 (2005): 110-118.</ref>
====Hunt and Hess scale====
The Hunt and Hess scale describes the severity of [[subarachnoid hemorrhage]], and is used as a predictor of survival.<ref name="pmid5635959">{{cite journal| author=Hunt WE, Hess RM| title=Surgical risk as related to time of intervention in the repair of intracranial aneurysms. | journal=J Neurosurg | year= 1968 | volume= 28 | issue= 1 | pages= 14-20 | pmid=5635959 | doi=10.3171/jns.1968.28.1.0014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5635959  }} </ref>
{| style="bo[[Link title]]rder: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Grading}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Associations}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Survival}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 1'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Asymptomatic
*Minimal headache and slight neck stiffness
| style="padding: 5px 5px; background: #F5F5F5;" |
*70% survival
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 2'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Moderate to severe headache
*Neck stiffness
*No neurologic deficit except [[cranial nerve palsy]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*60% survival
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 3'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Drowsy
*Minimal neurologic deficit
| style="padding: 5px 5px; background: #F5F5F5;" |
*50% survival
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 4'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Stuporous]]
*Moderate to severe [[hemiparesis]]
*Early decerebrate rigidity
*Vegetative disturbances
| style="padding: 5px 5px; background: #F5F5F5;" |
*20% survival
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 5'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Deep coma
*[[Decerebrate rigidity]]
*[[Moribund]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*10% survival
|}
====Fisher Grade====
The Fisher Grade classifies the appearance of subarachnoid hemorrhage on [[CT scan]]. It is highly predictive of vasospasm<ref>{{cite journal |author=Fisher C, Kistler J, Davis J |title=Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning |journal=Neurosurgery |volume=6 |issue=1 |pages=1-9 |year=1980 |pmid=7354892}}</ref>
{| style="bo[[Link title]]rder: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Grading}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Amount of blood shown on initial CT scans}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Incidence of symptomatic vasospasm}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 1'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*No hemorrhage evident
| style="padding: 5px 5px; background: #F5F5F5;" |
* 21%
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 2'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Subarachnoid hemorrhage less than 1 mm thick
*No clots
| style="padding: 5px 5px; background: #F5F5F5;" |
* 25%
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 3'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Subarachnoid hemorrhage more than 1 mm thick
*localised clots
| style="padding: 5px 5px; background: #F5F5F5;" |
*> 30 %
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 4'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Subarachnoid hemorrhage of any thickness with intra-ventricular hemorrhage (IVH) or parenchymal extension or absent blood in basal cisterns
| style="padding: 5px 5px; background: #F5F5F5;" |
*> 30 %
|}
 
====World Federation of Neurosurgeons====
In assessing outcome of subarachnoid hemorrhage, the World Federation of Neurosurgeons classification recommended use of the [[Glasgow coma scale|Glasgow Coma Scale]].<ref>{{cite journal |author=Teasdale G, Drake C, Hunt W, Kassell N, Sano K, Pertuiset B, De Villiers J |title=A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies |journal=J Neurol Neurosurg Psychiatry |volume=51 |issue=11 |pages=1457 |year=1988 |pmid=3236024}}</ref>
{| style="bo[[Link title]]rder: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Grading}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Glasgow Coma Score}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Motor deficit}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFF|Interpretation}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 1'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*15
| style="padding: 5px 5px; background: #F5F5F5;" |
*Absent
| style="padding: 5px 5px; background: #F5F5F5;" |
*Maximum score of 15 has the best prognosis
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 2'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*13-14
| style="padding: 5px 5px; background: #F5F5F5;" |
*Absent
| style="padding: 5px 5px; background: #F5F5F5;" |
*Scores of 8 or above have a good chance for recovery
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 3'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*13-14
| style="padding: 5px 5px; background: #F5F5F5;" |
*Present
| style="padding: 5px 5px; background: #F5F5F5;" |
*Scores of 8 or above have a good chance for recovery
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 4'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*7-12
| style="padding: 5px 5px; background: #F5F5F5;" |
*Absent/Present
| style="padding: 5px 5px; background: #F5F5F5;" |
*Scores of 8 or above have a good chance for recovery
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 5'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*3-6
| style="padding: 5px 5px; background: #F5F5F5;" |
*Absent/Present
| style="padding: 5px 5px; background: #F5F5F5;" |
*Minimum score of 3 has the worst prognosis
*Scores of 3-5 are potentially fatal, especially if accompanied by fixed pupils or absent oculovestibular responses
|}
====Ogilvy and Carter====
Ogilvy and Carter is  a combination of clinical and radiological findings. It combined the patient age, Hunt and Hess and Fisher Scales as well as aneurysm size and location to create a new grading system and only surgically treated patients were included in the study.<ref name=Rosen>Rosen, David S., and R. Loch Macdonald. "Subarachnoid hemorrhage grading scales." Neurocritical care 2.2 (2005): 110-118.</ref>
 
One point is given for each of the following variables:
*Age greater than 50
*Hunt and Hess grade 4 to 5 (in coma)
*Fisher grade score 3 to 4
*Aneurysm size >10 mm
*An additional point is added for a giant posterior circulation aneurysm (≥25 mm)


After the SAH is treated the patients can experience prolonged, even permanently reoccurring headaches.
{| style="bo[[Link title]]rder: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Grading}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Outcomes}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 1'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* 78% good to excellent outcomes
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 2'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* 78% good to excellent outcomes
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 3'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*67% good outcomes
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 4'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*25% good outcomes
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Grade 5'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*None with grade 5 had surgery.
|}


==References==
==References==
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Latest revision as of 19:27, 14 December 2016

Subarachnoid Hemorrhage Microchapters

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Overview

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Differentiating Subarachnoid Hemorrhage from other Diseases

Epidemiology and Demographics

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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)

Risk Factors/Prevention
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Medical Measures to Prevent Rebleeding
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Cerebral Vasospasm and DCI
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Sara Mehrsefat, M.D. [3]

Overview

Natural history

Following rupture of an aneurysm, the blood directly release into the cerebrospinal fluid (CSF) under arterial pressure. As the blood spreads quickly into the CSF, it rapidly increasing intracranial pressure.[1]  Increased intracranial pressure (ICP) occurs secondary to the following factors, including:[2]

Depending on the location of the aneurysm, the blood can spread into:

The bleeding usually lasts only a few seconds. However, rebleeding can be considered as one of the complication which can occur within the first day.[3]

Independent predictors of rebleeding after subarachnoid hemorrhage may include:[4][5][6]

  • The Hunt-Hess grade on admission
  • High bleeding pressure
  • Presence of sentinel headache prior to SAH
  • Early ventriculostomy
  • High blood pressure prior to event

The vasospasm usually occurs following subarachnoid hemorrhage and typically begins no earlier than day three after hemorrhage and peak at days seven to eight. it is thought that the blood clots release a spasmogenic substances following blot clots lysis which can result in vasospasm. The vasospasm can lead to ischemia of the brain which is usually characterized as a single cortical infarcts near the site of the ruptured aneurysm in most case. ischemia of the brain usually results in neurologic deterioration in level of consciousness or new focal neurologic deficits.[7][8]

Risk factors for developing vasospasm may include:[9][10] [11][12]

  • Severe bleeding
  • Bleeding the major intracerebral blood vessels
  • Age less than 50 years
  • Hyperglycemia 

Complications

Complications of SAH can be acute, subacute, or chronic.

Prognosis

Nearly half the cases of SAH are either dead or moribund before they reach a hospital. Of the remainder, a further 10-20% die in the early weeks in hospital from rebleeding. Delay in diagnosis of minor SAH without coma (or mistaking the sudden headache for migraine) contributes to this mortality. Patients who remain comatose or with persistent severe deficits have a poor prognosis.[3]

Following conditions associated with poorer outcome:[15][16][17][18][19][20]

Grading scales

There are several grading scales available for subarachnoid hemorrhage. These have been derived by retrospectively matching characteristics of patients with their outcomes. In addition to the ubiquitously used Glasgow Coma Scale, three other specialized scores are in use.[21][22]

Hunt and Hess scale

The Hunt and Hess scale describes the severity of subarachnoid hemorrhage, and is used as a predictor of survival.[23]

Grading Associations Survival
Grade 1
  • Asymptomatic
  • Minimal headache and slight neck stiffness
  • 70% survival
Grade 2
  • 60% survival
Grade 3
  • Drowsy
  • Minimal neurologic deficit
  • 50% survival
Grade 4
  • 20% survival
Grade 5
  • 10% survival

Fisher Grade

The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan. It is highly predictive of vasospasm[24]

Grading Amount of blood shown on initial CT scans Incidence of symptomatic vasospasm
Grade 1
  • No hemorrhage evident
  • 21%
Grade 2
  • Subarachnoid hemorrhage less than 1 mm thick
  • No clots
  • 25%
Grade 3
  • Subarachnoid hemorrhage more than 1 mm thick
  • localised clots
  • > 30 %
Grade 4
  • Subarachnoid hemorrhage of any thickness with intra-ventricular hemorrhage (IVH) or parenchymal extension or absent blood in basal cisterns
  • > 30 %

World Federation of Neurosurgeons

In assessing outcome of subarachnoid hemorrhage, the World Federation of Neurosurgeons classification recommended use of the Glasgow Coma Scale.[25]

Grading Glasgow Coma Score Motor deficit Interpretation
Grade 1
  • 15
  • Absent
  • Maximum score of 15 has the best prognosis
Grade 2
  • 13-14
  • Absent
  • Scores of 8 or above have a good chance for recovery
Grade 3
  • 13-14
  • Present
  • Scores of 8 or above have a good chance for recovery
Grade 4
  • 7-12
  • Absent/Present
  • Scores of 8 or above have a good chance for recovery
Grade 5
  • 3-6
  • Absent/Present
  • Minimum score of 3 has the worst prognosis
  • Scores of 3-5 are potentially fatal, especially if accompanied by fixed pupils or absent oculovestibular responses

Ogilvy and Carter

Ogilvy and Carter is a combination of clinical and radiological findings. It combined the patient age, Hunt and Hess and Fisher Scales as well as aneurysm size and location to create a new grading system and only surgically treated patients were included in the study.[22]

One point is given for each of the following variables:

  • Age greater than 50
  • Hunt and Hess grade 4 to 5 (in coma)
  • Fisher grade score 3 to 4
  • Aneurysm size >10 mm
  • An additional point is added for a giant posterior circulation aneurysm (≥25 mm)
Grading Outcomes
Grade 1
  • 78% good to excellent outcomes
Grade 2
  • 78% good to excellent outcomes
Grade 3
  • 67% good outcomes
Grade 4
  • 25% good outcomes
Grade 5
  • None with grade 5 had surgery.

References

  1. ↑ Schuss P, Konczalla J, Platz J, Vatter H, Seifert V, Güresir E (2013). "Aneurysm-related subarachnoid hemorrhage and acute subdural hematoma: single-center series and systematic review". J Neurosurg. 118 (5): 984–90. doi:10.3171/2012.11.JNS121435. PMID 23289820.
  2. ↑ Nornes H, Magnaes B (1972). "Intracranial pressure in patients with ruptured saccular aneurysm". J Neurosurg. 36 (5): 537–47. doi:10.3171/jns.1972.36.5.0537. PMID 5026540.
  3. ↑ 3.0 3.1 Biesbroek JM, van der Sprenkel JW, Algra A, Rinkel GJ (2013). "Prognosis of acute subdural haematoma from intracranial aneurysm rupture". J Neurol Neurosurg Psychiatry. 84 (3): 254–7. doi:10.1136/jnnp-2011-302139. PMID 23117495.
  4. ↑ Bederson JB, Connolly ES, Batjer HH, Dacey RG, Dion JE, Diringer MN; et al. (2009). "Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association". Stroke. 40 (3): 994–1025. doi:10.1161/STROKEAHA.108.191395. PMID 19164800.
  5. ↑ Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K; et al. (2012). "Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage". Neurology. 78 (1): 31–7. doi:10.1212/WNL.0b013e31823ed0a4. PMC 3466499. PMID 22170890.
  6. ↑ Inagawa T, Kamiya K, Ogasawara H, Yano T (1987). "Rebleeding of ruptured intracranial aneurysms in the acute stage". Surg Neurol. 28 (2): 93–9. PMID 3603360.
  7. ↑ 7.0 7.1 Haley EC, Kassell NF, Torner JC (1993). "A randomized controlled trial of high-dose intravenous nicardipine in aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study". J Neurosurg. 78 (4): 537–47. doi:10.3171/jns.1993.78.4.0537. PMID 8450326.
  8. ↑ 8.0 8.1 Weisberg LA (1979). "Computed tomography in aneurysmal subarachnoid hemorrhage". Neurology. 29 (6): 802–8. PMID 572002.
  9. ↑ 9.0 9.1 Kistler JP, Crowell RM, Davis KR, Heros R, Ojemann RG, Zervas T; et al. (1983). "The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study". Neurology. 33 (4): 424–36. PMID 6682190.
  10. ↑ Badjatia N, Topcuoglu MA, Buonanno FS, Smith EE, Nogueira RG, Rordorf GA; et al. (2005). "Relationship between hyperglycemia and symptomatic vasospasm after subarachnoid hemorrhage". Crit Care Med. 33 (7): 1603–9, quiz 1623. PMID 16003069.
  11. ↑ Ko SB, Choi HA, Carpenter AM, Helbok R, Schmidt JM, Badjatia N; et al. (2011). "Quantitative analysis of hemorrhage volume for predicting delayed cerebral ischemia after subarachnoid hemorrhage". Stroke. 42 (3): 669–74. doi:10.1161/STROKEAHA.110.600775. PMID 21257823.
  12. ↑ Charpentier C, Audibert G, Guillemin F, Civit T, Ducrocq X, Bracard S; et al. (1999). "Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage". Stroke. 30 (7): 1402–8. PMID 10390314.
  13. ↑ Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K; et al. (2012). "Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage". Neurology. 78 (1): 31–7. doi:10.1212/WNL.0b013e31823ed0a4. PMC 3466499. PMID 22170890.
  14. ↑ Graff-Radford NR, Torner J, Adams HP, Kassell NF (1989). "Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study". Arch Neurol. 46 (7): 744–52. PMID 2742543.
  15. ↑ McCarron MO, Alberts MJ, McCarron P (2004). "A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage". J Neurol Neurosurg Psychiatry. 75 (3): 491–3. PMC 1738971. PMID 14966173.
  16. ↑ Butzkueven H, Evans AH, Pitman A, Leopold C, Jolley DJ, Kaye AH; et al. (2000). "Onset seizures independently predict poor outcome after subarachnoid hemorrhage". Neurology. 55 (9): 1315–20. PMID 11087774.
  17. ↑ Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K; et al. (2012). "Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage". Neurology. 78 (1): 31–7. doi:10.1212/WNL.0b013e31823ed0a4. PMC 3466499. PMID 22170890.
  18. ↑ Herrer A (1971). "Leishmania hertigi sp. n., from the tropical porcupine, Coendou rothschildi Thomas". J Parasitol. 57 (3): 626–9. PMID 5090970.
  19. ↑ Zacharia BE, Ducruet AF, Hickman ZL, Grobelny BT, Fernandez L, Schmidt JM; et al. (2009). "Renal dysfunction as an independent predictor of outcome after aneurysmal subarachnoid hemorrhage: a single-center cohort study". Stroke. 40 (7): 2375–81. doi:10.1161/STROKEAHA.108.545210. PMID 19461033.
  20. ↑ Wartenberg KE, Mayer SA (2010). "Medical complications after subarachnoid hemorrhage". Neurosurg Clin N Am. 21 (2): 325–38. doi:10.1016/j.nec.2009.10.012. PMID 20380973.
  21. ↑ Rosen D, Macdonald R (2005). "Subarachnoid hemorrhage grading scales: a systematic review". Neurocrit Care. 2 (2): 110–8. PMID 16159052.
  22. ↑ 22.0 22.1 Rosen, David S., and R. Loch Macdonald. "Subarachnoid hemorrhage grading scales." Neurocritical care 2.2 (2005): 110-118.
  23. ↑ Hunt WE, Hess RM (1968). "Surgical risk as related to time of intervention in the repair of intracranial aneurysms". J Neurosurg. 28 (1): 14–20. doi:10.3171/jns.1968.28.1.0014. PMID 5635959.
  24. ↑ Fisher C, Kistler J, Davis J (1980). "Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning". Neurosurgery. 6 (1): 1–9. PMID 7354892.
  25. ↑ Teasdale G, Drake C, Hunt W, Kassell N, Sano K, Pertuiset B, De Villiers J (1988). "A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies". J Neurol Neurosurg Psychiatry. 51 (11): 1457. PMID 3236024.

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