Subarachnoid hemorrhage natural history, complications and prognosis
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Subarachnoid Hemorrhage Microchapters |
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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)
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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:
- 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.[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]
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.[3]
Hunt and Hess scale
The Hunt and Hess scale describes the severity of subarachnoid hemorrhage, and is used as a predictor of survival.[4]
| Grading | Associations | Survival |
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| Grade 1 |
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| Grade 2 |
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| Grade 3 |
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| Grade 4 |
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| Grade 5 |
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Fisher Grade
The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan. It is highly predictive of vasospasm[5]
| Grading | Amount of blood shown on initial CT scans | Incidence of symptomatic vasospasm |
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| Grade 1 |
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| Grade 2 |
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| Grade 3 |
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| Grade 4 |
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World Federation of Neurosurgeons
In assessing outcome of subarachnoid hemorrhage, the World Federation of Neurosurgeons classification recommended use of the Glasgow Coma Scale.[6]
| Grading | Glasgow Coma Score | Motor deficit | Interpretation |
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| Grade 1 |
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| Grade 2 |
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| Grade 3 |
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| Grade 4 |
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| Grade 5 |
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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.
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 | ||||||
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| Grade 1 |
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Grade 2 |
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Grade 3 |
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Grade 4 |
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| Grade 5 |
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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.
- ↑ Rosen D, Macdonald R (2005). "Subarachnoid hemorrhage grading scales: a systematic review". Neurocrit Care. 2 (2): 110–8. PMID 16159052.
- ↑ 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.