Sub Arachnoid hemorrhage - Clinicals, Diagnosis, and Management

Neurosurgery

Clinicals - History

Fact Explanation
Introduction Bleeding into the sub arachnoid space called Sub Arachnoid hemorrhage. This is common in 35-65 year age group and incidence is around 8;100 000 per year. Majority of cases are due to rupture of saccular aneurysm rupture. Introduction
Bleeding into the sub arachnoid space called Sub Arachnoid hemorrhage. This is common in 35-65 year age group and incidence is around 8;100 000 per year. Majority of cases are due to rupture of saccular aneurysm rupture.
Sudden onset severe headache There will be sudden onset (with in minutes to seconds) severe headache (thunderclap headache) . patient will describe this as the 'worst headache ever'. Pain will be an occipital pain. Patient will commonly present these symptoms following staining/ after sexual intercourse. Sudden onset severe headache
There will be sudden onset (with in minutes to seconds) severe headache (thunderclap headache) . patient will describe this as the 'worst headache ever'. Pain will be an occipital pain. Patient will commonly present these symptoms following staining/ after sexual intercourse.
Nausea and vomiting Patient will develop nausea and vomiting following leaking of the blood causing irritation and with increase intracranial pressure. Nausea and vomiting
Patient will develop nausea and vomiting following leaking of the blood causing irritation and with increase intracranial pressure.
Sudden onset transient loss of consciousness, mood and personality changes Brain ischemia due to vasospasm and irritation of the brain matter with blood can present with these symptoms. Sudden onset transient loss of consciousness, mood and personality changes
Brain ischemia due to vasospasm and irritation of the brain matter with blood can present with these symptoms.
confusion, irritability, drowsiness or coma for few days Minor leak of blood from few days will present as these symptoms. confusion, irritability, drowsiness or coma for few days
Minor leak of blood from few days will present as these symptoms.
Seizures With the vasospasm following bleeding can cause brain ischemia causing neuronal damage. So this can be associated with abnormal neuronal transmission of the impulses. Seizures
With the vasospasm following bleeding can cause brain ischemia causing neuronal damage. So this can be associated with abnormal neuronal transmission of the impulses.
visual problems Visual problems like double vision (with Oculomotor nerve palsy), sudden loss of vision, blurring can be seen. visual problems
Visual problems like double vision (with Oculomotor nerve palsy), sudden loss of vision, blurring can be seen.
pain on retraction/ stiffness of the neck and back, photophobia Meningeal irritation with leaked blood will causes symptoms of meningism. pain on retraction/ stiffness of the neck and back, photophobia
Meningeal irritation with leaked blood will causes symptoms of meningism.
features suggestive of focal neurological signs With brain ischemia there will be focal neurological symptoms like muscle paralysis, paresthesia, cranial nerve involvement.
Third cranial nerve (Oculomotor nerve) involvement with posterior communicating artery involvement will manifest as limited eye movements (Unable to look downward and outward), ptosis and photophobia.
features suggestive of focal neurological signs
With brain ischemia there will be focal neurological symptoms like muscle paralysis, paresthesia, cranial nerve involvement.
Third cranial nerve (Oculomotor nerve) involvement with posterior communicating artery involvement will manifest as limited eye movements (Unable to look downward and outward), ptosis and photophobia.
Past medical history of diagnosed aneurysms patient diagnosed with aneurysms are at higher risk of developing Sub Arachnoid hemorrhage. Past medical history of diagnosed aneurysms
patient diagnosed with aneurysms are at higher risk of developing Sub Arachnoid hemorrhage.
Recent history of trauma to head Trauma can induce Sub Arachnoid hemorrhage with rupture of blood vessels/ aneurysm. Recent history of trauma to head
Trauma can induce Sub Arachnoid hemorrhage with rupture of blood vessels/ aneurysm.
History of polycystic kidney disease or features suggestive of chronic renal failure (reduced urine out put, generalized body swelling, anaemia) Patient with polycystic kidney disease are susceptible to develop aneurysms as it weaken the blood vessel wall with increase intra vascular blood pressure. History of polycystic kidney disease or features suggestive of chronic renal failure (reduced urine out put, generalized body swelling, anaemia)
Patient with polycystic kidney disease are susceptible to develop aneurysms as it weaken the blood vessel wall with increase intra vascular blood pressure.
past medical history of bleeding diathesis Excessive bleeding tendency will mimic the bleeding even with minor blood vessel damage. past medical history of bleeding diathesis
Excessive bleeding tendency will mimic the bleeding even with minor blood vessel damage.
Past medical history of hypertension (high blood pressure) and dyslipidaemia. These are acquired risk factors for development of aneurysms and rupture. Past medical history of hypertension (high blood pressure) and dyslipidaemia.
These are acquired risk factors for development of aneurysms and rupture.
History of diagnosed coactation of aorta As coactation of aorta can increase blood pressure this also a diagnosed predisposing factor for development of Sub Arachnoid hemorrhage. History of diagnosed coactation of aorta
As coactation of aorta can increase blood pressure this also a diagnosed predisposing factor for development of Sub Arachnoid hemorrhage.
History of smoking and drug abuse These are also risk factors for weakening the vessel wall increasing risk of developing Sub Arachnoid hemorrhage. History of smoking and drug abuse
These are also risk factors for weakening the vessel wall increasing risk of developing Sub Arachnoid hemorrhage.
Drug history of anticoagulation Drugs like waferin, enoxaparin and increases the bleeding tendency. Drug history of anticoagulation
Drugs like waferin, enoxaparin and increases the bleeding tendency.
In a pregnant patient history of Pregnancy-induced hypertension in this pregnancy/ previous pregnancies Patients with pregnancy induce hypertension are at risk of rupture of intra cranial blood vessels. In these patients vessel wall can not bear the sudden onset tension caused by hypertension. In a pregnant patient history of Pregnancy-induced hypertension in this pregnancy/ previous pregnancies
Patients with pregnancy induce hypertension are at risk of rupture of intra cranial blood vessels. In these patients vessel wall can not bear the sudden onset tension caused by hypertension.
History of diagnosed conditions like Systemic lupus erythematosus Systemic lupus erythematosus like diseases causing vascuitis can induce rupture of blood vessels. History of diagnosed conditions like Systemic lupus erythematosus
Systemic lupus erythematosus like diseases causing vascuitis can induce rupture of blood vessels.
History of diagnosed genetic disorders like , Ehlers-Danlos syndrome, Klippel-Trenaunay-Weber syndrome These patients are genetically susceptible to develop aneurysms by disturbing the normal vessel wall formation. History of diagnosed genetic disorders like , Ehlers-Danlos syndrome, Klippel-Trenaunay-Weber syndrome
These patients are genetically susceptible to develop aneurysms by disturbing the normal vessel wall formation.
history of systemic/ cerebral Infections with bacterial/ fungal Bacterial/ fungal infection in vessel wall may leads to weaken the vessel wall formation of aneurysms. history of systemic/ cerebral Infections with bacterial/ fungal
Bacterial/ fungal infection in vessel wall may leads to weaken the vessel wall formation of aneurysms.
Family history of similer disease condition/ strokes There is genetics susceptibility to develop subarachnoid hemorrhage. Family history of similer disease condition/ strokes
There is genetics susceptibility to develop subarachnoid hemorrhage.
Chest pain, palpitation suggestive of cardiac involvement With Sub Arachnoid hemorrhage there will be a activation of sympathetic nervous system. this releases the adrenaline into the circulation. this leads to cardiac complications like arrhythmias and cardiac arrest. Chest pain, palpitation suggestive of cardiac involvement
With Sub Arachnoid hemorrhage there will be a activation of sympathetic nervous system. this releases the adrenaline into the circulation. this leads to cardiac complications like arrhythmias and cardiac arrest.
difficulty in breathing sudden onset increased pressure with Sub Arachnoid hemorrhage will cause complications (pulmonary oedems) in lungs due to increased pressure in pulmonary circulation. difficulty in breathing
sudden onset increased pressure with Sub Arachnoid hemorrhage will cause complications (pulmonary oedems) in lungs due to increased pressure in pulmonary circulation.

Clinicals - Examination

Fact Explanation
General examination In general examination should look for anaemia, level of hydration, presence of drowsiness, confusion or coma General examination
In general examination should look for anaemia, level of hydration, presence of drowsiness, confusion or coma
neck stiffness and positive kernig's sign These signs will be positive with meningeal irritation. neck stiffness and positive kernig's sign
These signs will be positive with meningeal irritation.
visual impairment There will be double vision, defect in papillary reflex following 3rd cranial nerve palsy. Fundoscopic examination will reveals vitrious haemorrhage, papilloedema. visual impairment
There will be double vision, defect in papillary reflex following 3rd cranial nerve palsy. Fundoscopic examination will reveals vitrious haemorrhage, papilloedema.
Focal neurological signs Neurologic examination reveals alteration in mental status (confusion/ drowsiness), development of seizures, hemiplegia, paresthesias, visual disturbance. Recent asymmetrical findings in neurological examination will suggest cerebral patology. Focal neurological signs
Neurologic examination reveals alteration in mental status (confusion/ drowsiness), development of seizures, hemiplegia, paresthesias, visual disturbance. Recent asymmetrical findings in neurological examination will suggest cerebral patology.
Evidence of recent trauma to head Can look for any wounds, bruises over the head. Evidence of recent trauma to head
Can look for any wounds, bruises over the head.
Evidence of increased bleeding tendency multiple bruising patches, patechiae, mucosal bleeding (gum bleeding, epistaxis, haematuria, pv bleeding). Evidence of increased bleeding tendency
multiple bruising patches, patechiae, mucosal bleeding (gum bleeding, epistaxis, haematuria, pv bleeding).
Abdominal examination Look for evidence of polycystic kidney disease.
eg: General examination will reveals anaemia, wasting, generalized body swelling. Abdominal examination will reveals ballotable bilateral kidneys. There will be hepatosplenomegally as well.
Abdominal examination for presence of abdominal aortic aneurysm (pulsatile abdominal lump) will be useful as aneurysms can occur in all types of vessels.
Abdominal examination
Look for evidence of polycystic kidney disease.
eg: General examination will reveals anaemia, wasting, generalized body swelling. Abdominal examination will reveals ballotable bilateral kidneys. There will be hepatosplenomegally as well.
Abdominal examination for presence of abdominal aortic aneurysm (pulsatile abdominal lump) will be useful as aneurysms can occur in all types of vessels.
Cardiovascular examination General examination for features of dydlipidaemia like xantholesma, corneal arcus. measure Blood pressure to assess the presence of hypertension.
Proper cardiovascular examination for cardiac arrhythmias (irregularly irregular pulse), coactation of aorta (radio-radial, radio-femoral delay).
Cardiovascular examination
General examination for features of dydlipidaemia like xantholesma, corneal arcus. measure Blood pressure to assess the presence of hypertension.
Proper cardiovascular examination for cardiac arrhythmias (irregularly irregular pulse), coactation of aorta (radio-radial, radio-femoral delay).
Evidence of genetic disorders like Marfan syndrome, Ehlers-Danlos syndrome, Klippel-Trenaunay-Weber syndrome Marfan syndrome- lens dislocation, arachnodactyly, armspan more than height, scoliosis, high arch palate, joint hypermobility.

Ehlers-Danlos syndrome- mitral valve prolapse, hyperelastic skin, gastrointestinal bleeding, loose hypermobile joints.

Klippel-Trenaunay-Weber syndrome- port wine stain, varicose veins, limb hypertrophy.
Evidence of genetic disorders like Marfan syndrome, Ehlers-Danlos syndrome, Klippel-Trenaunay-Weber syndrome
Marfan syndrome- lens dislocation, arachnodactyly, armspan more than height, scoliosis, high arch palate, joint hypermobility.

Ehlers-Danlos syndrome- mitral valve prolapse, hyperelastic skin, gastrointestinal bleeding, loose hypermobile joints.

Klippel-Trenaunay-Weber syndrome- port wine stain, varicose veins, limb hypertrophy.
features suggestive of Systemic lupus erythematosus Skin rash, photosensitivity, serositis, joint involvement and features suggestive of multi organ involvement. features suggestive of Systemic lupus erythematosus
Skin rash, photosensitivity, serositis, joint involvement and features suggestive of multi organ involvement.

Investigations - Diagnosis

Fact Explanation
CT scan of the brain This will confirm the diagnosis. new CT scans with non contrast CT can detect more than 90% of Sub Arachnoid hemorrhage with in first 48 hours and 100% if carried out with in 6 hours. The location of the sub arachnoid hemorrhage usually guides where the aneurysm is. Contrast enhanced CT will show the arterio-venous malformation but have to do only after the non contrast CT. Late presentation, small volume of hemorrhage or anemia would be the causes for negative non contrast CT. The Fisher grading system is used to classify sub arachnoid hemorrhage and degree and the location of the hemorrhage are significant prognostic factors. CT scan of the brain
This will confirm the diagnosis. new CT scans with non contrast CT can detect more than 90% of Sub Arachnoid hemorrhage with in first 48 hours and 100% if carried out with in 6 hours. The location of the sub arachnoid hemorrhage usually guides where the aneurysm is. Contrast enhanced CT will show the arterio-venous malformation but have to do only after the non contrast CT. Late presentation, small volume of hemorrhage or anemia would be the causes for negative non contrast CT. The Fisher grading system is used to classify sub arachnoid hemorrhage and degree and the location of the hemorrhage are significant prognostic factors.
Lumbar puncture and CSF studies If the clinical suspicious is Sub Arachnoid hemorrhage, but the CT findings are negative, This will be the next investigation option. Before the lumbar punture contra indications has to be excluded such as increased intra cranial pressure, significant mass effect and hydrocephalus. Lumbar punture must be avoided if CT shows evidence of bleeding, because of risk of further bleeding with reduction of intracranial pressure.
CSF will be blood stained and will be yellow in colour due to xanthochromic after few hours. CSF will also contain breakdown products of haemoglobin.
Billirubin will be present in CSF .
Lumbar puncture and CSF studies
If the clinical suspicious is Sub Arachnoid hemorrhage, but the CT findings are negative, This will be the next investigation option. Before the lumbar punture contra indications has to be excluded such as increased intra cranial pressure, significant mass effect and hydrocephalus. Lumbar punture must be avoided if CT shows evidence of bleeding, because of risk of further bleeding with reduction of intracranial pressure.
CSF will be blood stained and will be yellow in colour due to xanthochromic after few hours. CSF will also contain breakdown products of haemoglobin.
Billirubin will be present in CSF .
Digital substract angiography/ CT angiogram This will identify the site of aneurysms. Common sites are junction between posterior communicating artery and internal carotid artery, bifurcation of the middle cerebral artery and junction between anterior cerebral artery and anterior communicating artery. Digital substract angiography/ CT angiogram
This will identify the site of aneurysms. Common sites are junction between posterior communicating artery and internal carotid artery, bifurcation of the middle cerebral artery and junction between anterior cerebral artery and anterior communicating artery.
Magnetic Resonant Imaging scan This is equal or inferior to non contrast CT scan in diagnosing SAH and may not be that much visible in first 48 hours. But MRI is indicated when the angiogram doesn't show an Arterio Venous Malformation (AVM) or detecting spinal AVM. It is useful in monitoring unruptured aneurysm. Magnetic Resonant Imaging scan
This is equal or inferior to non contrast CT scan in diagnosing SAH and may not be that much visible in first 48 hours. But MRI is indicated when the angiogram doesn't show an Arterio Venous Malformation (AVM) or detecting spinal AVM. It is useful in monitoring unruptured aneurysm.
Electrocardiography (ECG) Patients with SAH can develop myocardial infarction though rare which is due to the catecholamine secretion and autonomic stimulation with the brain insult. The possible changes would be; nonspecific ST and T wave changes, decreased PR intervals, iIncreased QRS intervals, increased QT intervals, presence of U waves and arrythmias. Electrocardiography (ECG)
Patients with SAH can develop myocardial infarction though rare which is due to the catecholamine secretion and autonomic stimulation with the brain insult. The possible changes would be; nonspecific ST and T wave changes, decreased PR intervals, iIncreased QRS intervals, increased QT intervals, presence of U waves and arrythmias.
Transcranial Doppler ultrasound This will give an idea about the blood flow of cerebral vessels and useful in identifying brain hypoperfusion. Transcranial Doppler ultrasound
This will give an idea about the blood flow of cerebral vessels and useful in identifying brain hypoperfusion.

Investigations - Management

Fact Explanation
FBC During follow up this is useful to assess the associated anaemia condition and need of blood transfusion. Also can identify any associated infections. FBC
During follow up this is useful to assess the associated anaemia condition and need of blood transfusion. Also can identify any associated infections.
CT scanning This is useful in assessing the complications associated with Sub Arachnoid hemorrhage like rebleeding and hydrocephalus. CT scanning
This is useful in assessing the complications associated with Sub Arachnoid hemorrhage like rebleeding and hydrocephalus.
Digital substract angiography This will be helpful during pre-operative and post operative follow up. Digital substract angiography
This will be helpful during pre-operative and post operative follow up.
MRI This is useful in follow up of unruptured small aneurysm. MRI
This is useful in follow up of unruptured small aneurysm.
FBC This will be useful in looking for platelet count, haemoglobin level and WBC count when preparing the patient for invasive procedures and surgeries. FBC
This will be useful in looking for platelet count, haemoglobin level and WBC count when preparing the patient for invasive procedures and surgeries.
Clotting profile with PT/ INR, APTT These test also useful to assess the clotting status of the patient. Clotting profile with PT/ INR, APTT
These test also useful to assess the clotting status of the patient.
Renal function tests like serum electrolylres, serum creatinine, blood urea Assessment of the renal function of the patient is useful during imaging and pre operatively to assess the fitness for surgery. Renal function tests like serum electrolylres, serum creatinine, blood urea
Assessment of the renal function of the patient is useful during imaging and pre operatively to assess the fitness for surgery.
ECG These will be helpful in pre-operative fitness assessment specially in elderly poppulation. ECG
These will be helpful in pre-operative fitness assessment specially in elderly poppulation.
Chest X ray This will give an idea about lung status and this use before surgical procedures to assess the fitness. Chest X ray
This will give an idea about lung status and this use before surgical procedures to assess the fitness.
Blood grouping and cross matching This need to be done pre operatively and blood should be preserved. Blood grouping and cross matching
This need to be done pre operatively and blood should be preserved.
Staging the mortality in Sub Arachnoid hemorrhage No signs; mortality 0% - Grade I
Neck stiffness and cranial nerve palsies; mortality 11% - Grade II
Drowsiness; mortality 37% - Grade III
Drowsy with hemiplegia; mortality 71% - Grade IV
Prolonged coma; mortality 100% Grade V
Staging the mortality in Sub Arachnoid hemorrhage
No signs; mortality 0% - Grade I
Neck stiffness and cranial nerve palsies; mortality 11% - Grade II
Drowsiness; mortality 37% - Grade III
Drowsy with hemiplegia; mortality 71% - Grade IV
Prolonged coma; mortality 100% Grade V
Relative risks of rupture for an aneurysm according to International Study of Unruptured Intracranial Aneurysm (2003) Relative risks of rupture for an aneurysm 7-12mm across is 3.3; If the diameter is > 12mm, the relative risk is17 times that for aneurysm <7mm across Relative risks of rupture for an aneurysm according to International Study of Unruptured Intracranial Aneurysm (2003)
Relative risks of rupture for an aneurysm 7-12mm across is 3.3; If the diameter is > 12mm, the relative risk is17 times that for aneurysm <7mm across
The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan None evident - Grade I
Less than 1 mm thick - Grade II
More than 1 mm thick - Grade III
Diffuse or none with intraventricular hemorrhage or parenchymal extension - Grade IV
The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan
None evident - Grade I
Less than 1 mm thick - Grade II
More than 1 mm thick - Grade III
Diffuse or none with intraventricular hemorrhage or parenchymal extension - Grade IV
World Federation of Neurological Surgeons (WFNS) grading systems Glasgow Coma Score (GCS) of 15, absent motor deficit - Grade 1
GCS of 13-14, absent motor deficit - Grade 2
GCS of 13-14, motor deficit present - Grade 3
GCS of 7-12, motor deficit absent or present - Grade 4
GCS of 3-6, motor deficit absent or present - Grade 5
World Federation of Neurological Surgeons (WFNS) grading systems
Glasgow Coma Score (GCS) of 15, absent motor deficit - Grade 1
GCS of 13-14, absent motor deficit - Grade 2
GCS of 13-14, motor deficit present - Grade 3
GCS of 7-12, motor deficit absent or present - Grade 4
GCS of 3-6, motor deficit absent or present - Grade 5
Hunt and Hess grading system Unruptured aneurysm - Grade 0
Asymptomatic or mild headache and slight nuchal rigidity - Grade I
Fixed neurologic deficit without acute meningeal/brain reaction - Grade Ia
Cranial nerve palsy, moderate to severe headache, nuchal rigidity - Grade II
Mild focal deficit, lethargy, or confusion - Grade III
Stupor, moderate to severe hemiparesis, early decerebrate rigidity - Grade IV
Deep coma, decerebrate rigidity, moribund appearance - Grade V
Hunt and Hess grading system
Unruptured aneurysm - Grade 0
Asymptomatic or mild headache and slight nuchal rigidity - Grade I
Fixed neurologic deficit without acute meningeal/brain reaction - Grade Ia
Cranial nerve palsy, moderate to severe headache, nuchal rigidity - Grade II
Mild focal deficit, lethargy, or confusion - Grade III
Stupor, moderate to severe hemiparesis, early decerebrate rigidity - Grade IV
Deep coma, decerebrate rigidity, moribund appearance - Grade V
Ultra sound scan of abdomen This is to screen coexisting renal or hepatic cysts which are associated with polycystic kidney disease. Ultra sound scan will also detect abdominal aortic aneurysm. Ultra sound scan of abdomen
This is to screen coexisting renal or hepatic cysts which are associated with polycystic kidney disease. Ultra sound scan will also detect abdominal aortic aneurysm.

Management - Supportive

Fact Explanation
Resuscitation and stabilization of the patient. Sub arachnoid haemorhage is a medical emergency where the initial steps need stabilization of the patient including ABC management. Airway of the patient should be secured. Airway secretions during seizures, defective swallowing ability can lead to airway obstruction. Secretions should be sucked out and can be temporally maintained with an oral airway, when there is persistent obstruction and high risk of aspiration immediate intubation with endotracheal tube is beneficial.

Breathing of the patient can be affected by increased intracranial pressure causing respiratory center suprresion. In these kind of instances immediate intubation with ventilatory support should be given in an ICU setup.

Even though the blood pressure would be elevated during initial phase circulatory collapse could occur due to carciac center inhibition due to increased intracranial pressure, so adequate fluid resuscitation with inotrop support may be needed.

When the patients are having seizures it should be actively managed and prevented because it could further impede the cerebral perfusion.
Resuscitation and stabilization of the patient.
Sub arachnoid haemorhage is a medical emergency where the initial steps need stabilization of the patient including ABC management. Airway of the patient should be secured. Airway secretions during seizures, defective swallowing ability can lead to airway obstruction. Secretions should be sucked out and can be temporally maintained with an oral airway, when there is persistent obstruction and high risk of aspiration immediate intubation with endotracheal tube is beneficial.

Breathing of the patient can be affected by increased intracranial pressure causing respiratory center suprresion. In these kind of instances immediate intubation with ventilatory support should be given in an ICU setup.

Even though the blood pressure would be elevated during initial phase circulatory collapse could occur due to carciac center inhibition due to increased intracranial pressure, so adequate fluid resuscitation with inotrop support may be needed.

When the patients are having seizures it should be actively managed and prevented because it could further impede the cerebral perfusion.
Bed rest, Nursing in a dark, quiet room Bed rest will help to stabilize the patient which minimize the further progression. When the diagnose is confirmed as Sub Arachnoid hemorrhage ICU admition will be needed. Quiet, dark room will supply the maximum low stressful environment to the patient and it will allow resting. Bed rest, Nursing in a dark, quiet room
Bed rest will help to stabilize the patient which minimize the further progression. When the diagnose is confirmed as Sub Arachnoid hemorrhage ICU admition will be needed. Quiet, dark room will supply the maximum low stressful environment to the patient and it will allow resting.
Close monitoring Close monitoring of the patient's general condition, blood pressure, pulse rate, respiratory rate, pupillary reaction, Glasgow coma scale need to be done. Close monitoring
Close monitoring of the patient's general condition, blood pressure, pulse rate, respiratory rate, pupillary reaction, Glasgow coma scale need to be done.
Relief anxiety Anxiolytics like benzodiazepine can be use to relief anxiety. This will reduce the stress and calm down the patient. Relief anxiety
Anxiolytics like benzodiazepine can be use to relief anxiety. This will reduce the stress and calm down the patient.
Maintain hydration Hydration should be maintained adequately. If patient can not take orally nasogastric tube insertion can be done. Intravenous fluid replacement will also useful. Maintain hydration
Hydration should be maintained adequately. If patient can not take orally nasogastric tube insertion can be done. Intravenous fluid replacement will also useful.
Pain management Opioid analgesics will be useful in pain management. This will reduce the distress of the patient. Pain management
Opioid analgesics will be useful in pain management. This will reduce the distress of the patient.
Stool softeners This is to reduce training, As straining can worsen the bleeding. Stool softeners
This is to reduce training, As straining can worsen the bleeding.
Control hypertension Adequate antihypertensive agents (eg; beta blockers, calcium channel blockers) need to be given while continuously monitoring the patients blood pressure. Control hypertension
Adequate antihypertensive agents (eg; beta blockers, calcium channel blockers) need to be given while continuously monitoring the patients blood pressure.
Treat seizure If the patients develops seizures tratment with anti convulsant medication with phenytoin, phenobarbital will be needed. Treat seizure
If the patients develops seizures tratment with anti convulsant medication with phenytoin, phenobarbital will be needed.
If the patient is comatose Intubated and mechanically ventilation will be needed. Nutrition supplymentation and hydration can be done via nasogastric tubes or via parenteral rout. If the patient is comatose
Intubated and mechanically ventilation will be needed. Nutrition supplymentation and hydration can be done via nasogastric tubes or via parenteral rout.
Catheretization This will be important in assessing the urine out put with out disturbing the patient, Also it will allow minimal mobilization. Catheretization
This will be important in assessing the urine out put with out disturbing the patient, Also it will allow minimal mobilization.
Prevent Deep vein thrombosis As these patient need to kept with minimal mobilization during pre operative period and they will have to rest for long time post operatively Prevent Deep vein thrombosis is very important. Compression stockings, intermittent pneumatic compression of the calves will be useful in here. Prevent Deep vein thrombosis
As these patient need to kept with minimal mobilization during pre operative period and they will have to rest for long time post operatively Prevent Deep vein thrombosis is very important. Compression stockings, intermittent pneumatic compression of the calves will be useful in here.
Osmotic agents (eg, mannitol) and loop diuretics (eg, furosemide) These will be useful in presence of incresed intracranial pressure. Osmotic agents (eg, mannitol) and loop diuretics (eg, furosemide)
These will be useful in presence of incresed intracranial pressure.
Anti emetics Anti emetics like promethazine will be useful in the presence of recurrent vomiting. Anti emetics
Anti emetics like promethazine will be useful in the presence of recurrent vomiting.
Patient education The patient and the family members should be thoroughly educated regarding the condition. Specially unexpectedly previously healthy adults could get SAH will be life threatening. During the resuscitation phase in high risk patients the family should be emphasized regarding the illness and risk on life as well as the care of disabled patient following recovery. This should include the hydration, nutrition, prevention of DVT, prevention of bed sores and first aid care during seizures.

The procedures available such as aneurysm clipping coiling should be explained including the risks associated with such invasive measures.

Patient should be thoroughly emphasized on importance of regular follow up such as for assessing progression of aneurysm, for followup imaging, anti epileptics, hypertension management.
Patient education
The patient and the family members should be thoroughly educated regarding the condition. Specially unexpectedly previously healthy adults could get SAH will be life threatening. During the resuscitation phase in high risk patients the family should be emphasized regarding the illness and risk on life as well as the care of disabled patient following recovery. This should include the hydration, nutrition, prevention of DVT, prevention of bed sores and first aid care during seizures.

The procedures available such as aneurysm clipping coiling should be explained including the risks associated with such invasive measures.

Patient should be thoroughly emphasized on importance of regular follow up such as for assessing progression of aneurysm, for followup imaging, anti epileptics, hypertension management.
Preventive measures The screening of the general population is not cost effective as this is an rare entity. So screening the patients with high risk such as patients and families with adult poly cystic kidney disease would detect the unruptured aneurysms and can direct preventive invasive procedures such as clipping when indicated.

Hypertension should be controlled with adequate anti hypertensives as high systemic blood pressure is associated with aneurysm rupture.

Smoking should be stopped.
Preventive measures
The screening of the general population is not cost effective as this is an rare entity. So screening the patients with high risk such as patients and families with adult poly cystic kidney disease would detect the unruptured aneurysms and can direct preventive invasive procedures such as clipping when indicated.

Hypertension should be controlled with adequate anti hypertensives as high systemic blood pressure is associated with aneurysm rupture.

Smoking should be stopped.

Management - Specific

Fact Explanation
Nimodipine This is a calcium channel blocker which prevents arterial vasoapasm. As blood in the sub arachnoid space act as an irritant, it can induce vasospasm caosing reduction of blood supply to brain. So this oral nimodipine 60mg 4 hourly will prevent brain ischemia. Nimodipine
This is a calcium channel blocker which prevents arterial vasoapasm. As blood in the sub arachnoid space act as an irritant, it can induce vasospasm caosing reduction of blood supply to brain. So this oral nimodipine 60mg 4 hourly will prevent brain ischemia.
Craniotomy and Clipping the aneurysm Clipping the aneurysm is done with titanium. This can stop rebleeds. This is the best option for asymptomatic patients and patients with minimal symptoms (less or equal to grade II). The rupture of the aneurysm during the procedure and post operative epilepsy are known complications associated with this procedure. Craniotomy and Clipping the aneurysm
Clipping the aneurysm is done with titanium. This can stop rebleeds. This is the best option for asymptomatic patients and patients with minimal symptoms (less or equal to grade II). The rupture of the aneurysm during the procedure and post operative epilepsy are known complications associated with this procedure.
Inserting a coil to the aneurysm This can be done at the time of angiography with platinum coils. Intra cranial stenting and balloon remodeling will be useful in treating the aneurysms with wide neck. Inserting a coil to the aneurysm
This can be done at the time of angiography with platinum coils. Intra cranial stenting and balloon remodeling will be useful in treating the aneurysms with wide neck.
management of hydrocephalus Acute hydrocephalus occur with the development of sub arachnoid haemorrhage due to the obstruction to the out flow tract.Chronic hydrocephalus can occur few weeks after (2-6 weeks) due to the impaired absorption of the CSF folllowing formation of adhesions. In symptomatic patients or patients with progessive development of the condition will requre tratment. Ventriculo-peritoneal shunt will be useful in removing the excessive CSF. Endoscopic ventriculostomy using ventriculoscopy is another surgical treatment option available. management of hydrocephalus
Acute hydrocephalus occur with the development of sub arachnoid haemorrhage due to the obstruction to the out flow tract.Chronic hydrocephalus can occur few weeks after (2-6 weeks) due to the impaired absorption of the CSF folllowing formation of adhesions. In symptomatic patients or patients with progessive development of the condition will requre tratment. Ventriculo-peritoneal shunt will be useful in removing the excessive CSF. Endoscopic ventriculostomy using ventriculoscopy is another surgical treatment option available.

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