ICH Subarachnoid hemorrhage
Posted On May 3, 2020
This review will discuss the nontraumatic subarachnoid hemorrhage, which consisted of about 3% of all acute stroke.
Cause: Cerebral aneurysm
- For discussion of unruptured aneurysm, click here.
Clinical
- Sudden onset severe headache
- Neck stiffness
- May occur during activity or rest
Hunt & Hess Scale
- Grade 1 – Asymptomatic, or mild headache and neck stiffness
- Grade 2 – Severe headache, stiff neck, no neuro deficit except cranial nerve palsy
- Grade 3 – Drowsy or confused, mild focal neuro deficit
- Grade 4 – Stuporous, moderate or severe hemiparesis
- Grade 5 – Coma, decerebrate posturing
Testing:
- CT head,
- if done within first 6 hours of onset, close to 100% sensitive.
- done within 24 hours, about 90% sensitive
- If CT is negative, LP may be considered, or proceed with CTA.
- If onset over 2 weeks, need CTA or MRA of head.
Management
- Transfer to tertiary care center with neurosurgery, endovascular specialists and neuro intensive care.
- Blood pressure
- maintain systolic < 160 or mean BP < 110
- avoid vasodilators, no nitroprusside, nitroglycerin
- Antiplatelets reversal: if patient is on antiplatlet
- single dose of desmopressin DDAVP iv at 0.4 mcg/kg
- For platelet count < 100,000, platelet transfusion 1 apheresis unit
- If on warfarin or NOAC
- General Care
- Cardiac, neuro, hemodyamic monitoring
- Monitor for pulmonary edema, cardiac arrhythmia
- Swallow eval
- Deep vein thrombosis prophylaxis with SCD
- Nimodipine 60 mg q4 hour po or NG
- Seizure and Anticonvulsant
- Prophylactic anticonvulsant using Dilantin is controversial, consider Keppra
- 6-18% have seizure
- EEG to check for nonconvulsive seizure
- Hyperglycemia management
- Pain control
- avoid aspirin
- use Acetaminophin, Tramadol codeine
- Treat fever and infection
- Stool softener
- Cardiac, neuro, hemodyamic monitoring
Prognosis is based on
- Level of conscious on admission
- Age
- Amount of blood on initial head CT
Specialized treatment
- Aneurysm:
- surgical clipping or endovascular coiling is the only effective treatment to prevent rebleeding
- preferably performed as early as feasible, within 24 hours
- Hydrocephalus and Increased intracranial pressure
- may need intracranial pressure monitoring
- External ventricular drain (EVD), monitor for infection
- Osmotic therapy, diuresis
- Hemicraniectomy
- Vasospasm and cerebral ischemia:
- usually begin 3 days after onset
- peak at 7-8 days
- nimodipine, euvolemia
- large artery focal spasm: balloon angioplasty, intrarterial vasodilator are options
- Hyponatremia, SIADH
- maintain euvolemia
- free water restriction