0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50
Subarachnoid Hemorrhage (SAH) 1389■Four-vessel angiography: to identify source of bleeding & any coex-
isting vascular anomalies
■ECG may show arrhythmia or myocardial ischemia (as secondary
phenomenon due to central sympathetic activation)
differential diagnosis
■Imaging studies will distinguish btwn aneurysm & AVM, and btwn
subarachnoid & intracerebral hemorrhage; primary intracerebral
hemorrhage leads to marked focal deficit
■Traumatic cause of SAH usually evident from history
■Acute bacterial meningitis is distinguished by CSF findings
management
■Supportive care
■Strict bed rest
■Analgesics for headache (but avoid antiplatelet meds)
■Keep pt sedated & blood pressure at low-normal levels
■Anticonvulsant prophylaxis for seizures
■Nimodipine to reduce risk of vasospasm
specific therapy
■Early surgery or endovascular treatment for accessible aneurysm or
AVM, if feasible, unless pt deeply comatose
follow-up
n/a
complications and prognosis
Complications
■Recurrence of hemorrhage common w/ aneurysmal source; pre-
vented by early surgery
■Vasospasm: may lead to ischemic neurologic deficit in first 21 days
after SAH despite prophylaxis w/ nimodipine; treat w/ volume
expansion & induced hypertension only if underlying lesion has
been surgically treated & no other lesions exist; angioplasty may be
required
■Acute hydrocephalus (from impaired CSF absorption) suggested by
somnolence, poor attention, confusion; treat by shunt
■Cardiac arrhythmias: treat as appropriate
■Cerebral salt-wasting may lead to hyponatremiaPrognosis
■After first aneurysmal SAH, approximately 50% of pts die, many
before arriving in hospital; another 20% die from re-bleeding unless