Subarachnoid hemorrhage natural history, complications and prognosis

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Subarachnoid Hemorrhage Microchapters

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Overview

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Pathophysiology

Causes

Differentiating Subarachnoid Hemorrhage from other Diseases

Epidemiology and Demographics

Risk Factors

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Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

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Medical Therapy

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Primary Prevention

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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

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Case #1

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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]

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.[2]

Hunt and Hess scale

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[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

  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. 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.
  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.

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