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Subarachnoid haemorrhage

Background knowledge ๐Ÿง 

Definition

  • Subarachnoid haemorrhage (SAH) is bleeding into the subarachnoid space
  • Usually caused by rupture of a cerebral aneurysm
  • Leads to increased intracranial pressure and potential brain damage

Epidemiology

  • Incidence: approximately 6-10 per 100,000 people per year
  • More common in women and in older adults
  • High morbidity and mortality rate
  • Significant risk factors: hypertension, smoking, family history of aneurysms

Aetiology and Pathophysiology

  • Rupture of saccular (berry) aneurysms (most common)
  • Arteriovenous malformations (AVMs)
  • Trauma
  • Extension of intracerebral haemorrhage
  • Idiopathic (in some cases)
  • Pathophysiology: Blood in subarachnoid space leads to irritation of meninges and increased intracranial pressure

Clinical Features ๐ŸŒก๏ธ

Symptoms

  • Sudden onset of severe headache (thunderclap headache)
  • Nausea and vomiting
  • Photophobia
  • Neck stiffness
  • Loss of consciousness (in severe cases)
  • Focal neurological deficits

Signs

  • Meningism (neck stiffness, positive Brudzinski and Kernig signs)
  • Papilledema
  • Retinal hemorrhages
  • Cranial nerve palsies
  • Decreased level of consciousness
  • Hemiparesis (if large hemorrhage)

Investigations ๐Ÿงช

Tests

  • CT head (first-line)
  • Lumbar puncture for xanthochromia (if CT negative but suspicion remains)
  • MRI/MRA (for further assessment)
  • CT angiography (to locate aneurysm)
  • Digital subtraction angiography (gold standard for aneurysm detection)
  • Blood tests: full blood count, clotting profile, electrolytes

Management ๐Ÿฅผ

Management

  • Resuscitation and stabilization (ABCDE approach)
  • Early neurosurgical consultation
  • Nimodipine to prevent vasospasm
  • Endovascular coiling or surgical clipping of aneurysm
  • Management of complications (e.g., hydrocephalus, rebleeding)
  • Supportive care: pain management, antiemetics, stool softeners
  • Intensive monitoring (ICU if necessary)

Complications

  • Rebleeding
  • Vasospasm and delayed cerebral ischemia
  • Hydrocephalus
  • Hyponatremia (SIADH)
  • Seizures
  • Cognitive and functional deficits
  • Death (if severe or untreated)

Prognosis

  • Mortality rate: approximately 30-40%
  • Poor outcomes associated with delayed diagnosis and treatment
  • Better prognosis with early intervention and effective management
  • Rehabilitation is crucial for recovery
  • Regular follow-up required to monitor for complications

Key Points

  • Early recognition and treatment are essential
  • High index of suspicion in patients with sudden severe headache
  • Multidisciplinary approach improves outcomes
  • Regular monitoring and prevention of complications are key

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