Management of Subarachnoid Hemorrhage Gregory W Balturshot, M.D. Central Ohio Neurological Surgeons May 24, 2013
Introduction • Risk factors - hypertension, smoking, cocaine, female gender, age >50 • Genetic risk factors - Moya Moya, Ehlers-Danlos, PCKD, Marfan’s, fibrimuscular dysplasia
Clinical Presentation • 80% describe the sudden onset of worst headache on my life • 20% experience ‘sentinal headache’ 2-8 weeks before SAH • other symptoms include photophobia, nausea and vomiting, seizures, loss of consciousness
Diagnosis • Noncontrast CT - sensitivity 92-95% • Lumbar Puncture - Xanthrochromia may take 12 hrs to appear after initial SAH. differentiates from a ‘traumatic tap’ • MRI/MRA - sensitivity 55-93% for aneurysms >5mm it is 85-100% • CTA - 77-100% and 85-100%. Additional information such as wall calcification, intraluminal thrombus, relationship to the clinoids
Initial Critical Care Management • Stablization of systemic oxygenation/hemodynamics • ICP control • BP control • Seizure prophylaxis • Prevention of aneurysm rebleeding (9-17% within 72hrs)
Clip vs Coil • ISAT - International subarachnoid aneurysm trial • 2134 good grade patients with <10 mm aneurysms in the anterior circulation were randomized to clipping or coiling. • Death and dependency @ 1 yr 23.5% vs 30.9% • Rebleeding rates?
Clip vs Coil • TEAM approach • Factors include the clinical state of the patient, anatomic location, neck to dome ratio (wide neck), hematoma with mass effect