Subarachnoid Hemorrhage

Intracranial saccular aneurysms represent the most common etiology of nontraumatic subarachnoid hemorrhage (SAH), with about 80% of SAH resulting from ruptured aneurysms. Pathophysiology Aneurysms are acquired lesions related to hemodynamic stress on the arterial walls at bifurcation points and bends. Saccular or berry aneurysms are specific to the intracranial arteries because their walls lack an external elastic lamina and contain a very thin adventitiafactors that may predispose to the formation of aneurysms. An additional feature is that they lie unsupported in the subarachnoid space. Aneurysms mostly arise from the terminal portion of the internal carotid artery (ICA) and from the major branches of the anterior portion of the circle of Willis. In a 25-year autopsy study of 125 patients with ruptured or unruptured aneurysms conducted at Johns Hopkins, hypertension, cerebral atherosclerosis, vascular asymmetry in the circle of Willis, persistent headache, pregnancy-induced hypertension, long-term analgesic use, and family history of stroke all were correlated positively with the formation of saccular aneurysms. The occurrence of aneurysms in children indicates the role of intrinsic vascular factors. A number of disease states resulting in weakness of the arterial wall are associated with an increased incidence of berry aneurysms. Hypertension (previously documented acute severe hypertension with diastolic value over 110 mm Hg), smoking, alcohol, multiple aneurysms, increasing aneurysm size, fatty metamorphosis of the liver, long-term analgesic use, and oral contraceptives have been linked to aneurysmal subarachnoid hemorrhage. Disease states associated with higher incidence of berry aneurysms include the following: Increased blood pressure - Fibromuscular dysplasia, polycystic kidney disease, and aortic coarctation Increased blood flow - Cerebral arteriovenous malformation (AVM); persistent carotid-basilar anastomosis; ligated, aplastic, or hypoplastic contralateral vessel Blood vessel disorders Systemic lupus erythematosus (SLE), Moyamoya disease[1] , and granulomatous angiitis Genetic - Marfan syndrome, Ehlers-Danlos syndrome, Osler-Weber-Rendu syndrome, pseudoxanthoma elasticum, and Klippel-Trenaunay-Weber syndrome Congenital - Persistent fetal circulation and hypoplastic/absent arterial circulation Metastatic tumors to cerebral arteries -Atrial myxoma, choriocarcinoma, and undifferentiated carcinoma Infectious - Bacterial, fungal CT without contrast CT is the most sensitive imaging study in subarachnoid hemorrhage.

 CT scan reveals subarachnoid hemorrhage in the right sylvian fissure; no evidence of hydrocephalus is apparent.

CT scan reveals subarachnoid hemorrhage in the sylvian fissure, right more than left.

A 47-year-old woman presented with headache and vomiting; her CT scan in the emergency department revealed subarachnoid hemorrhage.

Findings may be negative in 10-15% of patients with SAH. Maximum sensitivity is within 24 hours after the event; sensitivity is 80% at 3 days, 50% at 1 week. When carried out within 6 hours of headache onset, CT has 100% sensitivity and specificity. Look for evidence of hydrocephalus (trapped temporal horns and "Mickey Mouse" appearance of ventricular system). Look for intraparenchymal clot, intraventricular hematoma, and interhemispheric hematoma. Degree and location of SAH are significant prognostic factors. The Fisher grading system is used to classify SAH, as follows: - Grade I - No subarachnoid blood seen on CT scan - Grade II - Diffuse or vertical layers of SAH less than 1 mm thick - Grade III - Diffuse clot and/or vertical layer greater than 1 mm thick - Grade IV - Intracerebral or intraventricular clot with diffuse or no subarachnoid blood Cerebral angiography To assess the following: Vascular anatomy

Cerebral

angiogram

reveals

middle

cerebral

artery

aneurysm.

Cerebral

angiogram

reveals

middle

cerebral

artery

aneurysm.

Cerebral angiogram (lateral view) reveals a large aneurysm arising from the left anterior choroidal artery.

 Cerebral angiogram (anteroposterior view) reveals a large aneurysm arising from the left anterior choroidal artery. Site of bleed (location of aneurysm that bled this time) Presence of other aneurysms (about 20% have multiple aneurysms) Operative planning Negative angiographic findings do not rule out aneurysm. Approximately 1020% of patients with clinically diagnosed SAH (CT and/or lumbar puncture) have negative angiographic findings. A repeat angiogram is usually required in 10-21 days.