Subarachnoid hemorrhage resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Overview

Subarachnoid Hemorrhage (SAH) is defined as bleeding into the subarachnoid space (the space between the arachnoid membrane and the pia mater of the brain or spinal cord). This consists of:

• Aneurysmal SAH
• Non-aneurysmal SAH

Time of Onset

Time of onset is defined as when the patient was last awake and symptom-free or known to be “normal".

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Management

Diagnosis

Check vitals Stabilize ABC Brief Hx Rapid physical exam - neuro exam, NIHSS Activate stroke team Stat fingerstick Basic labs, troponin, EKG NPO Obtain stroke protocol

Non-contrast CT (or MRI)

Bleed

Positive

Negative

Ischemic Stroke

Intracerebral Hemorrhage

Subarachnoid Hemorrhage

Strong Suspicion for SAH

Management of ICH

May consider lumber puncture

Management of SAH

Xanthochromia or bloody CSF

Yes

No

No SAH

Strong Suspicion for SAH

Traumatic tap? Poor Technique?

Yes

No

CTA/MRA Consult to Neurosurgeon Talk with superior

Normal CSF

Obtain more Hx and Investigation Rule out other causes Analgesia

Treatment

Suspicion of Aneurysmal SAH

Head CT

Intraparenchymal Hemorrhage Hydrocephalus Intraventricular Hemorrhage

NICU Management Stabilize ABC Brief Hx PE - GCS, Hunt-Hess Score, BP CBC, PT/PTT/INR, Type & CM, EKG IVF -N/S Consult to Neurosurgery D/C all antiplatelets Reverse all Anticoagulation DVT Prophylaxis -Pneumatic Compression Stockings Urgent meds Fosphenytoin 20 mg/kg IV bolus Analgesia - IV morphine Stool Softeners - docusate/senna PPI -Esomeprazole Oral Nimodipine - 60 mg 4 hourly Antipyretic IV Mannitol - 20% 1g/kg bolus if ↑ICP is suspected Assess for Tranexamic acid or Aminocaproic acid

Surgery

Large intraparenchymal Hge (>50 mLs) Middle Cerebral artery aneurysm

Age > 70 years Poor grade (WFNS IV/V) Aneurysm of Basilar Apex

Microsurgical Clipping

Endovascular Coiling

Delayed Follow-up vascular imaging Consider retreatment with coiling or clipping, if there is remnant

NICU Management

Manage Complications

Prevent

↑ICP Management NB - Avoid Hyperventilation

Symptomatic Vasospasm

HypoNa

Rebleeding

Vasospasm and delayed cerebral ischemia

Oral Nimodipine 60 mg 4 hourly Maintain Euvolemia - N/S or packed RBC transfusion in anemic paatients ↓ Induced HTN with phenylephrine, norepinephrine, dopamine ↓ Balloon angioplasty ↓ Intra-arterial vasodilators -nicardipine milrinone

Isotonic or Hypertonic saline (3%) Fludrocortisone acetate

BP control Maintain Euvolemia Tranexamic acid

Oral Nimodipine Maintain Euvolemia

Monitor

Neurostatus Vasospasm - daily TCD, CT/MR Perfusion imaging Seizures Volume status Strict glucose control Hyponatremia Heparin-induced thrombocytopenia - Platelet count/PT/PTT DVT

Algorithms are based on recommendations AHA/ASA for the management of aneurysmal subarachnoid hemorrhage (2012)

SAH Scoring Systems

Hunt & Hess

Grades	Clinical Features
I	Asymptomatic, mild headache, slight nuchal rigidity
II	Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy
III	Drowsiness/confusion, mild focal neurologic deficit
IV	Stupor, moderate to severe hemiparesis
V	Coma, decerebrate posturing

World Federation of Neurological Surgeons (WFNS) SAH Grading Scale

Grades	GCS Score	Motor Deficit
I	15	Absent
II	13-14	Absent
III	13-14	Present
IV	7-12	Present or Absent
V	3-6	Present or Absent

Dos

• Obtain a brief hx with emphasis on time of onset, h/o trauma, seizures, or cocaine use.
• Withold antihypertensives in severely impaired consciousness and in the absence of ICP measurement because the cerebral perfusion pressure must be maintained.

Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) minus Intracranial Pressure (ICP)

• Oral nimodipine should be administered to all patients with aneurysmal SAH.
• Strict maintenance of euvolemia and normal circulating volume to prevent delayed cerebral ischemia.

SAH

• No prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasms.
• Fenestration of the lamina terminalis should not be routinely performed to reduce the rate of shunt-dependent hydrocephalus.
• Long term use of anticonvulsants is discouraged except if the patient have a known risk factor for delayed seizure disorder: prior seizure, intracerebral hematoma, intractable hypertension, infarction, or aneurysm in the middle cerebral artery.
• Administering large volume of hypotonic fluids and intravascular volme contraction is not recommended after aneurysmal SAH.
• Avoid hyperventilation as a measure to reduce elevated ICP; it may worsen vasospasm.
• Avoid nitroprusside or nitroglycerin for blood pressure control; it may increase the cerebral blood volume.