Subarachnoid hemorrhage natural history, complications and prognosis

	Subarachnoid Hemorrhage Microchapters
Home
Patient Information
Overview
Classification
Pathophysiology
Causes
Differentiating Subarachnoid Hemorrhage from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
CT
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012) Risk Factors/Prevention Natural History/Outcome Clinical Manifestations/Diagnosis Medical Measures to Prevent Rebleeding Surgical and Endovascular Methods Hospital Characteristics/Systems of Care Anesthetic Management Cerebral Vasospasm and DCI Hydrocephalus Seizures Associated With aSAH Medical Complications
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Subarachnoid hemorrhage natural history, complications and prognosis On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Subarachnoid hemorrhage natural history, complications and prognosis All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Subarachnoid hemorrhage natural history, complications and prognosis
CDC on Subarachnoid hemorrhage natural history, complications and prognosis
Subarachnoid hemorrhage natural history, complications and prognosis in the news
Blogs on Subarachnoid hemorrhage natural history, complications and prognosis
Directions to Hospitals Treating Subarachnoid hemorrhage
Risk calculators and risk factors for Subarachnoid hemorrhage natural history, complications and prognosis

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]

Complications

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

Acute:
- Coma and brainstem herniation due to increased intracranial pressure (ICP)
- 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]

Hunt and Hess scale

The Hunt and Hess scale describes the severity of subarachnoid hemorrhage, and is used as a predictor of survival.^[3]


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^[4]


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

The World Federation of Neurosurgeons classification:^[5]


Grading	Glasgow Coma Score	Motor deficit	Interpretation
Grade 1	15	Absent	Maximum score of 15 has the best prognosis
Grade 2	13-14	Absent
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

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.
↑ 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.

Template:WH Template:WS

[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.

[pmid5635959-3] 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.

[4] 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.

[5] 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.

[1]

[2]

[3]

[4]

[5]