Neurology 2011: SAH

Rx: Renounce raw conceit; find notes, morphine and pennies.

Refer neurosurgery

Reexamine CNS often

Chart BP, pupils, GCS

Fluids: SBP >160 (HHT = hypertensive hypervolaemic therapy... because hypotension causes vasospasm).

Nimodipine. Start by day 4 (asap on diagnosis!) till day 21 - three weeks.

Morphine + laxatives (opiates cause constipation).

Angiography: Sensitivity: 4 vessel angiography > CTA > MRA

Procedures: Clipping (craniotomy) or coiling (endovascular).

Tests

Angiogram: Sensitivity - 4 vessel angiography > CTA > MRA. CT detects >90% of SAHs.
LP: If CT negative and no c/i >12h after headache onset.
Early CSF uniformly bloody; later CSF shows xanthochromia.

S&S

Thunderclap headache, vomiting, collapse, seizures, coma, neck stiffness, Kernig's sign, retinal or subhyaloid haemorrhage.
Focal signs at presentation may suggest site of aneurysm (e.g. pupil change suggests CNIII palsy suggests PCA aneurysm).
Sentinal headache due to small warning leak from the offending aneurysm.

DD of thunderclap headache = D SUMMIT V

Dissection of carotid/vertebral artery

SAH

Unknwon cause

Meningitis

Migraine

Intracerebral bleed

Thrombosis cortical vein

Valsalva maneuvre

Complications

Prognosis

⅓ die immediately.

⅓ die within 1m from vasospasm or rebleed.

⅓ survive with or without neurological problems.

Grade I = No signs = 0% mortality.

Grade II = Necks stiffness, CN palsies = 11%.

Grade III = Drowsiness = 37%.

Grade IV = Drowsiness + hemiplegia = 71%.

Grade V = Prolonged coma = 100%.

Causes

Aneurysm rupture 80%.

AVM.

Unknown.

Risk factors

Smoking, hypertension, mycotic aneurysm, alcohol, bleeding disorder, low oestrogen (post-menopause).

Berry aneurysms are associated with:

Neurology 2011