Subarachnoid hemorrhage natural history, complications and prognosis

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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]

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.^[2]

Independent predictors of rebleeding after subarachnoid hemorrhage may include:^[3]

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

Complications

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

Acute:
- Coma and brainstem herniation due to increased intracranial pressure (ICP)
- Rebleeding
- Pulmonary edema ("neurogenic pulmonary edema") as a result of the suddenly increased ICP
- Cardiac arrhythmias and myocardial damage
- Hydrocephalus, which may also happen in the subacute time frame
Subacute:
- Vasospasm, leading to ischemia of the brain
- Hyponatremia (low sodium levels) - due to SIADH or cerebral salt wasting syndrome
Chronic:
- Long-term immobility
- Pneumonia and pulmonary embolism (due to immobility)
- SAH recurrence (20% within two weeks if the aneurysm is not secured by clipping or coiling)
- Persistent neurologic deficits

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.^[2]

Following conditions associated with poorer outcome:^[4]^[5]

Seizures occur during the first 24 hours
The combination of subarachnoid hemorrhage with preretinal hemorrhages (Terson's syndrome)

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.^[6]^[7]

Hunt and Hess scale

The Hunt and Hess scale describes the severity of subarachnoid hemorrhage, and is used as a predictor of survival.^[8]


Grading	Associations	Survival
Grade 1	Asymptomatic Minimal headache and slight neck stiffness	70% survival
Grade 2	Moderate to severe headache Neck stiffness No neurologic deficit except cranial nerve palsy	60% survival
Grade 3	Drowsy Minimal neurologic deficit	50% survival
Grade 4	Stuporous Moderate to severe hemiparesis Early decerebrate rigidity Vegetative disturbances	20% survival
Grade 5	Deep coma Decerebrate rigidity Moribund	10% survival

Fisher Grade

The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan. It is highly predictive of vasospasm^[9]


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.^[10]


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.^[7]

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

↑ 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.
↑ ^2.0 ^2.1 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.
↑ 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.
↑ 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.
↑ 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.
↑ Rosen D, Macdonald R (2005). "Subarachnoid hemorrhage grading scales: a systematic review". Neurocrit Care. 2 (2): 110–8. PMID 16159052.
↑ ^7.0 ^7.1 Rosen, David S., and R. Loch Macdonald. "Subarachnoid hemorrhage grading scales." Neurocritical care 2.2 (2005): 110-118.
↑ 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.
↑ 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.
↑ 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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[pmid23289820-1] 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.

[pmid23117495-2] 2.0 ^2.1 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.

[pmid3603360-3] 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.

[pmid14966173-4] 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.

[pmid11087774-5] 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.

[6] Rosen D, Macdonald R (2005). "Subarachnoid hemorrhage grading scales: a systematic review". Neurocrit Care. 2 (2): 110–8. PMID 16159052.

[Rosen-7] 7.0 ^7.1 Rosen, David S., and R. Loch Macdonald. "Subarachnoid hemorrhage grading scales." Neurocritical care 2.2 (2005): 110-118.

[pmid5635959-8] 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.

[9] 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.

[10] 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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