Module: Subarachnoid Hemorrhage (SAH)
Slides (3-11)
Question: You are called to evaluate a 48 y.o.
comatose male. The fundoscopic examination
(below) is consistent with:
CEREBROVASCULAR DISEASE V: SUBARACHNOID
HEMORRHAGE & NEUROVASCULAR IMAGING
Neelofer Shafi, MD
Assistant Professor of Neurology
University of Illinois at Chicago
[email protected]
Question Based Learning
Lecture Modules
• Subarachnoid Hemorrhage A. Subhyaloid hemorrhage
• Neurovascular Imaging B. Intraretinal hemorrhage
C. Papilledema
D. Vitreous hemorrhage
E. Papillitis
• Subhyaloid hemorrhage into a previously non-
existing space e.g between the posterior layer
of the vitreous and the retina
Causes and Presentation
• Causes
– Most common cause: trauma
– Most common cause of non-traumatic SAH:
aneurysm rupture
– Perimesencephalic or pretruncal SAH
• Presentation
– “Worse headache of my life”
– Sudden onset
– Meningismus
– Decreased level of consciousness
– Subhyaloid hemorrhage
– Retinal hemorrhage
– Vitreal hemorrhage (Terson’s syndrome)
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Causes and Presentation cont’d Management
• Rebleeding
– 4% in first 24h; 1% daily thereafter for 2
weeks
– Tx: SBP<160 mmHg until the aneurysm is
obliterated (clipping vs. coiling)
• Hydrocephalus
– Occurs in 20%-25% of the patients
– Tx: lumbar drain, external ventricular drain or
VPS
• Vasospasm
– Occurs within 3-21d and peaks on day 8
– 50%-70% of the patients. Half become
symptomatic (ischemia)
– Monitor with TCD or angiography
– Tx: Hypertension and euvolemia; nimodipine;
angioplasty; intraarterial papaverine or
verapamil
– Use of endothelin-1 antagonists
(clazosentan) and NO donors: investigational
• Cardiovascular
– Arrhythmia
– Myocardial stunning
– Elevation of cardiac enzymes (band necrosis)
• Seizures
– Occurs in 10%-20% of the patients
– Routine long-term use of AED is not
Diagnosis recommended
• Head CT (~8% is normal). Consider timing and • Neurogenic pulmonary edema
Hb • Hyponatremia
• Lumbar puncture (xanthochromia may require – Occurs in 10%-30% of the patients
at least 6h to develop) – SIADH versus cerebral salt wasting
• Angiography in nontraumatic SAH to identify – Tx: hypertonic treatment vs. fludrocortisone
the aneurysm acetate. Avoid using hypotonic solutions and
volume contraction
Predictors of Poor Outcome
• Overall mortality ~30%
• GCS and World Federation of Neurosurgeons
scales
• Age
• Amount of blood in the head CT (Fisher scale)
• Seizures
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Predictors of Poor Outcome cont’d II
WFNS
Grade Focal deficits GCS
1 Absent 15
2 Absent 13-14
3 Present 13-14
4 Present or absent 7-12
5 Present or absent 3-6
III
Fisher scale
Grade CT findings
1 None
2 Diffuse layer (<1 mm)
Clot or thick layer
3
(>1 mm)
4 ICH or IVH
Module: Neurovascular Imaging
Slides (12-28)
Notes:
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V cont’d VIII
• Patient presents with new onset of confusion
IV
IX
• Patient presents with new onset of neck pain
and vertigo
VII
• Patient presents with transient event of vertigo.
The exam is only significant for anisocoria
X Cavernous Malformation
• Sinusoidal vascular channels lined by a single
layer of endothelium
• Lack of intervening brain parenchyma
• Low flow → invisible to angio
• 80% are supratentorial
“Popcorn appearance” on MRI
• Familial cases: CCM1 gene in chromosome 7
• Sz is the most common presentation
• Annual risk of bleed: 0.7%-4.2%
• Surgical intervention if symptomatic and
accessible
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X Cavernous Malformation cont’d XII Dural AV Fistula (or Dural AVM)
• AV shunt from dural arterial supply to dural
venous drainage channel
• Blood supply usually from external carotid
• Most occur in the skull base in the posterior
fossa
• Presentation
– Headache, cranial neuropathy, pulsatile
tinnitus/audible bruit due to high flow, or
elevated ICP (dAVM>cAVM)
– Hemorrhage (subdural hematoma or ICH), or
seizure (dAVM<cAVM)
XI Cerebral Arteriovenous Malformations
• Tangle of arteries and veins without normal
intervening capillary beds
• Nidus
• High-flow with associated aneurysms (12%)
• Large majority is supratentorial
• Presentation
– ICH (50%); annual risk of bleed: 2%-3%
– Seizure (16%-53%)
– Headache (7%-48%)
– Stroke like symptoms (1%-40%)
• Surgical intervention depends on risk of bleed,
location, associated aneurysm, patient’s age XIII Dural AV Fistula (or Dural AVM)
and Spetzler-Martin grade • May be missed by CTA/MRA
• Surgical intervention depends on risk of bleed,
location, and symptoms
• Gamma knife does not work in this entity
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XIII Dural AV Fistula (or Dural AVM) cont’d XV Developmental Venous Anomaly cont’d
References
• Goldstein LB, et al. Guidelines for the primary
prevention of stroke: a guideline for healthcare
XIV Capillary Telangiectasia professionals from the American Heart
• Small dilated capillaries with normal intervening Association/American Stroke Association.
brain Stroke. 2011 Feb;42(2):517-84.
• Most occur in the pons • Furie KL, et al. Guidelines for the prevention of
• Low flow → invisible to angio stroke in patients with stroke or transient
• Usually found incidentally ischemic attack: a guideline for healthcare
• Rarely bleed professionals from the American Heart
• Mild enhancement in T1 Association/American Stroke Association.
Stroke. 2011 Jan;42(1):227-76.
• Morgenstern LB, et al. Guidelines for the
management of spontaneous intracerebral
hemorrhage: a guideline for healthcare
professionals from the American Heart
Association/American Stroke Association.
Stroke. 2010 Sep;41(9):2108-29.
• Bederson JB, et al. Guidelines for the
management of aneurysmal subarachnoid
hemorrhage: a statement for healthcare
professionals from a special writing group of
the Stroke Council, American Heart Association.
XV Developmental Venous Anomaly Stroke. 2009 Mar;40(3):994-1025.
• Usually congenital • Furie KL, et al. Oral Antithrombotic Agents for
• Radially arranged veins with a larger central the Prevention of Stroke in Nonvalvular Atrial
vein that drains into a dural sinus Fibrillation : A Science Advisory for Healthcare
• Drains normal tissue! Professionals From the American Heart
• Low flow Association/American Stroke Association. DOI:
• Usually an incidental finding 10.1161/STR.0b013e318266722a.
• 20% have associated cavernomas
• Annual risk of bleed 0.2%-0.6%
• Shows enhancement
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Answer Key
Question: You are called to evaluate a 48 y.o.
comatose male. The fundoscopic examination
(below) is consistent with:
A. Subhyaloid hemorrhage
B. Intraretinal hemorrhage
C. Papilledema
D. Vitreous hemorrhage
E. Papillitis
End of Lecture
Notes:
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