Subarachnoid Hemorrhage (SAH) HD

Subarachnoid haemorrhages most commonly occur due to rupture of an intracranial aneurysm. - Many of these patients suffer a minor haemorrhage (a.k.a., warning leak) in the preceding days or weeks. - The patient history may also reveal a connective tissue disease or polycystic kidney disease, both of which are associated with the presence of an intracranial aneurysm. Subarachnoid haemorrhages are characterized by the very sudden onset of a severe headache. - The rapid onset has been described as a thunderclap, because the headache reaches maximal intensity within seconds or minutes. In a large portion of cases, the headache begins during physical exertion. - The severity is another major clue, as even patients with a history of migraines will often describe this episode as the worst headache of their life. - Subarachnoid Haemorrhage is also often associated with brief loss of consciousness, nausea and vomiting, seizures, and photophobia and neck stiffness (both of which are signs of meningeal irritation). Abnormal findings on the physical examination can be very limited; many patients have normal neurologic examinations without any focal neurologic deficits. - Nuchal rigidity (as well as Kernig’s and Brudzinski’s sign) can occur due to meningeal irritation, but may not develop until several hours after the onset. - Fundoscopy can be difficult to perform due to photophobia, but if the retina is visualized, there may be papilledema due to increased intracranial pressure or a subhyaloid haemorrhage. - The ECG may show a variety of changes, ranging from ST-segment and T wave abnormalities, to QT interval prolongation, to arrhythmias. For example, this ECG example was taken from a patient with The first test to order is a non-contrast computed topography scan of the head, which is very sensitive if obtained within 24 hours of onset. - A lumbar puncture is only indicated if the CT is inconclusive and does reveal any contraindications. - The most characteristic finding in the cerebral spinal fluid is xanthochromia, which is due to the presence of bilirubin. Xanthochromia, however, is usually not present until several hours after the onset of the hemorrhage. Other suggestive findings include the presence of erythrocytes and an elevated opening pressure. - If either the head CT or lumbar puncture are indicative of a subarachnoid hemorrhage, then order an immediate neurosurgical consultation. - A digital subtraction angiography is the preferred test to identify the etiology of the bleed. - Aneurysms, if present, are usually occluded via surgical clipping or an endovascular coil. Initial management begins with patient stabilization and the correction of any physiologic derangements. In order to reduce hemodynamic fluctuations the patient should be placed in a dark and quiet room, and be made as comfortable as possible. - Stool softeners are required to reduce straining which can increase intracranial pressure. - In regards to analge