Subarachnoid hemorrhage

Tania Rebeiz MD (Dr. Rebeiz of the University of Chicago has no relevant financial relationships to disclose.)
James R Brorson MD (Dr. Brorson of the University of Chicago received consulting fees from the National Peer Review Corporation and Medico-legal Consulting.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released April 10, 1995; last updated April 3, 2017; expires April 3, 2020

This article includes discussion of subarachnoid hemorrhage and subarachnoid haemorrhage. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

The authors review the epidemiology, pathophysiology, natural history, diagnostic evaluation, and treatment of spontaneous subarachnoid hemorrhage and its secondary complications, including aneurysm rebleeding, hydrocephalus, hyponatremia, seizures, delayed cerebral ischemia, and cardiopulmonary problems. Newer hypotheses on the mechanism of delayed cerebral ischemia following subarachnoid hemorrhage are explained. Recommendations from the Neurocritical Care Society Guidelines and the American Heart Association/American Stroke Association guidelines for the management of aneurysmal subarachnoid hemorrhage are included. Evolving trends in the emergency room diagnosis of subarachnoid hemorrhage are critically reviewed.

Key points

 

• Subarachnoid hemorrhage, often occurring from rupture of an intracranial aneurysm, constitutes a life-threatening neurologic emergency.

 

• Subarachnoid hemorrhage typically presents with a sudden severe headache and neck stiffness, and can be complicated by fatal rebleeding, arterial vasospasm producing ischemia, seizures, metabolic derangements, and venous thrombosis.

 

• The diagnosis of subarachnoid hemorrhage is usually confirmed by a noncontrast head CT, which has very high sensitivity in the initial hours following headache onset. Failure to diagnose subarachnoid hemorrhage can have fatal consequences.

 

• Traditionally a lumbar puncture has been recommended to follow a negative head CT when subarachnoid hemorrhage is suspected, but in the emergency medicine literature there is an evolving acceptance of noninvasive evaluation for aneurysm with CT angiogram when initial plain CT is negative for a suspected hemorrhage.

 

• Securing of the underlying ruptured aneurysm with surgical clipping or endovascular coiling should be performed as soon as possible to limit the chance of aneurysm rebleeding.

 

• Treatment in a specialized neurointensive care setting is necessary to address the diverse possible complications including delayed cerebral ischemia and metabolic derangements.

Historical note and terminology

Subarachnoid hemorrhage is a devastating condition, often resulting in severe neurologic disability or death, in which blood extravasates into the subarachnoid space between the arachnoid membrane and the pia mater. The majority of nontraumatic subarachnoid hemorrhages are due to the rupture of a saccular intracranial aneurysm. Early autopsy descriptions of aneurysmal subarachnoid hemorrhage included “Observations on the Sanguineous Apoplexy” of Giovanni Morgagni (1682-1771) and the documentation of bilateral carotid aneurysms in a patient presenting with apoplexy and headache by Gilbert Blane (1749-1834) (DiLuna et al 2004). It was not until the end of the 19th century, due in part to the more detailed description of the signs and symptoms of subarachnoid hemorrhage and the technique of lumbar puncture, that the diagnosis of subarachnoid hemorrhage could be made. In 1927, Egaz Moniz was the first to successfully carry out cerebral angiography, enabling confirmation of the diagnosis of ruptured intracranial aneurysm in those patients presenting with signs and symptoms of subarachnoid hemorrhage (Moniz et al 1928). In 1973, computed tomography was introduced, facilitating the diagnosis of subarachnoid hemorrhage. Craniotomy and microsurgical clip obliteration was the main treatment method for aneurysms until 1991, when Guglielmi introduced the endovascular occlusion of aneurysm with electrolytically detachable coils (Connolly et al 2012). Since then, new advances in endovascular treatment have emerged, providing a widening array of options for treating aneurysms with challenging anatomy or location.

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