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Subarachnoid haemorrhage (Clinical presentation (Headache (Character …
Subarachnoid haemorrhage
Definition
Serious neurological
disorder due to bleeding into
the subarachnoid space
Pathophysiology
Bleeding into the subarachnoid space
Arterial source
Often berry aneurysm (sac-like structure)
Aetiology
Congenital
Berry aneurysm (bifurcations in CoW)
AVMs
Trauma
Clinical
presentation
Headache
Character
Worst ever
Blow to the back of the head
Radiation
Nil
Onset
Sudden
May have a preceeding 'warning'
headache (sentinel headache)
Site
Usually occipital
Associated symptoms
N&V
Photophobia
Neck pain
Drowsiness, confusion
Syncope, seizures
Timing
First and worst, then improves
Severity
Worst ever headache
Exacerbating/relieving
Brought on by exertion in some cases
e.g. post-coital
N&V
Photophobia
Neck pain
Drowsiness
Confusion
Syncope
Seizures
Diagnosis
Examination
Neuro limbs
May have focal deficit
Cranial nerves
Neck stiffness
Kernig's sign
Fundoscopy
Retinal, subhyaloid, vitreous bleeds
Investigations
Bloods
Clotting, FBC, U+E, glucose
Imaging
CXR (neurogenic pulmonary oedema)
Emergency CT head
Bedside
RR, sats
HR, BP
Temp
LP
If CT normal (not if raised ICP)
Do >12h after headache onset
Bloody early, then xanthochromic (yellow) after several hrs
Catheter or CT angiography
Identify single vs multiple aneurysms
History
PC/HPC
Rapid onset, 'worst ever'
Associated symptoms
Management
Referral
Hunt & Heiss severity scale
1 - asymptomatic, mild headache, slight nuchal rigidity
2 - mod-sev head, nuchal rigid, no neuro deficit except CN palsy
3 - drowsy/confused, mild focal neuro deficit
4 - stupor, mod-sev hemiparesis
5 - coma, decerebrate
Neurosurgery
ASAP
Definitive
Medical
Analgesia
IV codeine plus antiemetic (cyclizine)
CCB
E.g: nimodipine IV
MOA: reduces vasospasm thus
improves ischemic neuro deficit
Mannitol IV
MOA: reduces raised ICP
Surgical
Endovascular coiling
Preferred method
Surgical clipping
Balloon and stents
For wide aneurysms
Initial (ABCDE)
Regular BP, pupils and GCS review
Keep hydrated and BP stable
Risk factors
Alcohol
Hypertension
Smoking
CT disorder
Coagulation disorder
Complications
Cerebral ischemia
Hydrocephalus
Ventricular/lumbar drain
Rebleeding
Hyponatraemia
Fluid restriction