Subarachnoid hemorrhage - PowerPoint PPT Presentation

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Subarachnoid hemorrhage

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  1. Subarachnoid hemorrhage Dr. Ari Sami HussainNadhim Consultant Neurosurgeon Scxhoolof Medicine University of Sulaimani 2013 Dr. Ari Sami Hussain Nadhim

  2. SAH • Bleeding from intracranial vessels lie in the SA space which give off small perforating branches to the brain tissue or from an associated aneurysm. Dr. Ari Sami Hussain Nadhim

  3. Incidence • It represents about 5-10% of all non-traumatic ICH with an incidence of approximately 10-15/100 000 population per year Dr. Ari Sami Hussain Nadhim

  4. Causes of SAH • Rupture of a berry aneurysm. • Rupture of AVM (6%) (Children) • Rare Causes: • Bleeding from a tumor • Bleeding disorders • Blood dyscrasias • Rupture of spinal AVM • Undiagnosed cause in 15% Dr. Ari Sami Hussain Nadhim

  5. Presenting features: • Headache: • Sudden onset of a severe headache of a type not experienced by the patient • Described as a blow to the head Dr. Ari Sami Hussain Nadhim

  6. Deteriorated level of consciousness • Meningism • Headache, fever, neck stiffness, photophobia, and vomiting Dr. Ari Sami Hussain Nadhim

  7. Focal neurological signs: • Due to: • Concomitant ICH: • MCA (Temporal lobe and Parietal lobe), ACA (Frontal lobe) • Local pressure effect of aneurysm (PCA and 3rd nerve palsy) • Cerebral vasospasm ( 2-3 days after the bleeding) Dr. Ari Sami Hussain Nadhim

  8. Epilepsy • Optic fundi: papilloedema • Retinal hemorrhage (subhyaloid) • Reactive hypertension • pyrexia Dr. Ari Sami Hussain Nadhim

  9. Diagnosis: • History and examination: • Sudden severe headache • Decrease conscious state • Meningism Dr. Ari Sami Hussain Nadhim

  10. CT scan • It will show the hemorrhage in 95% of patients with SAH (if within 48 hours of the bled) • Hydrocephalus • ICH • Aneurysm or AVM • Tumor Dr. Ari Sami Hussain Nadhim

  11. Dr. Ari Sami Hussain Nadhim

  12. MRI • Not routinely used • Used in spinal AVM which cause SAH Dr. Ari Sami Hussain Nadhim

  13. CT/MR angiography • Non-invasive techniques • Will detect up to 95% of intracranial aneurysms Dr. Ari Sami Hussain Nadhim

  14. Dr. Ari Sami Hussain Nadhim

  15. LP: • Xanthochromia: • Allow CSF to drip into 3 consecutive tubes Dr. Ari Sami Hussain Nadhim

  16. Cerebral angiography • Aneurysm • AVM • Vessel spasm Dr. Ari Sami Hussain Nadhim

  17. Dr. Ari Sami Hussain Nadhim

  18. Aneurysm • The most common cause of SAH with a maximum incidence in the 4th-5th decades of life • The majority of aneurysms occur in constant positions of the circle of Willis and about 85% occur in the anterior half of the circle Dr. Ari Sami Hussain Nadhim

  19. Clinical presentation • Rupture • Compression from aneurysm sac • Visual • Cranial nerves • Pituitary • Brainstem • incidental Dr. Ari Sami Hussain Nadhim

  20. Management • Severity of initial hemorrhage • Rebleed: 50% within 6 weeks • Antifibrinolytic agents are not used because of thrombotic phenomena (DVT, cerebral thrombosis) Dr. Ari Sami Hussain Nadhim

  21. Cerebra vasospasm: • Hypertensive and hypervolemic therapy • Calcium channel blocking agents (Nimodipine) Dr. Ari Sami Hussain Nadhim

  22. Surgery: • Occlusion of the neck • Reinforcement of the sac • Proximal ligation of the feeding vessel • Endovascular procedures (detachable coils) Dr. Ari Sami Hussain Nadhim

  23. AVM • Most common cause of SAH in children and young patients • Clinical presentation: • Hemorrhage • Epilepsy • Headache • Progressive neurological deficits Dr. Ari Sami Hussain Nadhim

  24. Dr. Ari Sami Hussain Nadhim

  25. Management • Excision • Stereotactic radiosurgery • Embolisation Dr. Ari Sami Hussain Nadhim