Abstract
A 64-year-old female was brought to the emergency department of a tertiary care center by his son. She was apparently alright till 10 h back when she complained of sudden onset of severe headache followed by two episodes of vomiting and transient loss of consciousness. She was a known hypertensive for last 15 years, on Tab amlodipine 10 mg BD. On examination, patient had a GCS score of E4V5M6 (drowsy), with pupils bilaterally equal in size and reacting to light. There was presence of neck rigidity with no other motor/sensory deficits. Heart rate—92/min, BP—178/102 mmHg, SpO2—95% on face mask with oxygen flow @ 6 L/min. Chest and CVS examination findings were normal. Samples for lab testing were sent. Noncontrast CT head revealed blood in the right sylvian fissure. Cerebral DSA was carried out which confirmed the presence of right middle cerebral artery (M1) aneurysm 5.23 × 3.42 × 2.32 mm.
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References
Sodhi HS, Savardekar AR, Mohindra S, Chhabra R, Gupta V, Gupta SK. The clinical profile, management, and overall outcome of aneurysmal subarachnoid hemorrhage at the neurosurgical unit of a tertiary care center in India. J Neurosci Rural Pract. 2014;5:118–26.
Aggarwal A, Dhandapani S, Praneeth K, et al. Comparative evaluation of H&H and WFNS grading scales with modified H&H (sans systemic disease): a study on 1000 patients with subarachnoid haemorrhage. Neurosurg Rev. 2018;41:241–7.
Carpenter CR, Hussain AM, Ward MJ, Zipfel GJ, Fowler S, Pines JM, Sivilotti ML. Spontaneous subarachnoid hemorrhage: a systematic review and meta-analysis describing the diagnostic accuracy of history, physical examination, imaging, and lumbar puncture with an exploration of test thresholds. Acad Emerg Med. 2016;23(9):963–1003.
Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA. 2004;291:866–9.
Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency department. Emerg Med Clin North Am. 2003;21:73–87.
Abraham MK, Chang WW. Subarachnoid hemorrhage. Emerg Med Clin North Am. 2016;34:901–16.
Romanelli D, Farrell MW. AVPU (alert, voice, pain, unresponsive). Treasure Island: Stat Pearls Publishing; 2019.
Blok KM, Rinkel GJ, Majoie CB, et al. CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology. 2015;84(19):1927–32.
Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711–37.
Edlow JA, Figaji A, Samuels O. Emergency neurological life support: subarachnoid hemorrhage. Neurocrit Care. 2015;23(Suppl 2):S103–9.
Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28(1):14–20.
Teasdale GM, Drake CG, Hunt W, et al. A universal subarachnoid haemorrhage scale: report of a committee of the world federation of neurosurgical societies. J Neurol Neurosurg Psychiatry. 1988;51(11):1457.
Hunt WE, Kosnik EJ. Timing and perioperative care in intracranial aneurysm surgery. Clin Neurosurg. 1974;21:79–89.
Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6:1–9.
Frontera JA, Claassen J, Schmidt JM, Wartenberg KE, Temes R, Connolly ES Jr, et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. Neurosurgery. 2006;59:21–7.
Claassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Copeland D, Connolly ES, Mayer SA. Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke. 2001;32:2012–20.
Ogilvy CS, Carter BS. A proposed comprehensive grading system to predict outcome for surgical management of intracranial aneurysms. Neurosurgery. 1998;42:959–68.
Naval NS, Kowalski RG, Chang TR, Caserta F, Carhuapoma JR, Tamargo RJ, The SAH. Score: a comprehensive communication tool. J Stroke Cerebrovasc Dis. 2014;23:902–9.
Ogilvy CS, Cheung AC, Mitha AP, Hoh BL, Carter BS. Outcomes for surgical and endovascular management of intracranial aneurysms using a comprehensive grading system. Neurosurgery. 2006;59:1037–42.
Lozupone E, Piano M, Valvassori L, Quilici L, Pero G, Visconti E, Boccardi E. Flow diverter devices in ruptured intracranial aneurysms: a single-center experience. J Neurosurg. 2018;128:1037–43.
Pickard JD, Murray GD, Illingworth R, Shaw MD, Teasdale GM, Foy PM, Humphrey PR, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ. 1989;298(6674):636–42.
Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the neurocritical care society’s multidisciplinary consensus conference. Neurocrit Care. 2011;15(2):211–40.
Tanno Y, Homma M, Oinuma M, et al. Rebleeding from ruptured intracranial aneurysms in north eastern province of Japan: a cooperative study. J Neurosci. 2007;258:11–6.
Starke RM, Kim GH, Fernandez A, et al. Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke. 2008;39(9):2617–21.
Claassen J, Carhuapoma JR, Kreiter KT, Du EY, Connolly ES, Mayer SA. Global cerebral edema after subarachnoid hemorrhage: frequency, predictors, and impact on outcome. Stroke. 2002;33(5):1225–32.
Graff-Radford NR, Torner J, Adams HP, Kassell NF. Factors associated with hydrocephalus after subarachnoid hemorrhage: a report of the cooperative aneurysm study. Arch Neurol. 1989;46:744–52.
Chen S, Luo J, Reis C, Manaenko A, Zhang J. Hydrocephalus after subarachnoid hemorrhage: pathophysiology, diagnosis, and treatment. Biomed Res Int. 2017;2017:8584753.
Lu J, Ji N, Yang Z, Zhao X. Prognosis and treatment of acute hydrocephalus following aneurysmal subarachnoid haemorrhage. J Clin Neurosci. 2012;19:669–72.
Wartenberg KE, Mayer SA. Medical complications after subarachnoid hemorrhage. Neurosurg Clin North Am. 2010;21(2):325–38.
Naidech AM, Kreiter KT, Janjua N, et al. Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid haemorrhage. Circulation. 2005;112:2851–6.
Lee VH, Connolly HM, Fulgham JR, Manno EM, et al. Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: an underappreciated ventricular dysfunction. J Neurosurg. 2006;105:264–70.
Mayer SA, Li Mandri G, Sherman D, et al. Electrocardiographic markers of abnormal left ventricular wall motion in acute subarachnoid haemorrhage. J Neurosurg. 1995;83:889–96.
Chen S, Li Q, Wu H, et al. The harmful effects of subarachnoid hemorrhage on extracerebral organs. Biomed Res Int. 2014;2014:858496.
Alimohamadi M, Saghafinia M, Alikhani F, et al. Impact of electrolyte imbalances on the outcome of aneurysmal subarachnoid hemorrhage: a prospective study. Asian J Neurosurg. 2016;11:29–33.
Kumar MA, Levine J, Faerber J, Elliott JP, Winn HR, et al. The effects of red blood cell transfusion on functional outcome after aneurysmal subarachnoid hemorrhage. World Neurosurg. 2017;108:807–16.
Dhar R, Zazulia AR, Derdeyn CP, Diringer MN. RBC transfusion improves cerebral oxygen delivery in subarachnoid hemorrhage. Crit Care Med. 2017;45:653–9.
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Multiple Choice Questions
Multiple Choice Questions
-
1.
A patient having moderate headache with nuchal stiffness belongs to which grade on Hunt and Hess scale?
-
(a)
I
-
(b)
II
-
(c)
III
-
(d)
IV
-
(a)
-
2.
Which one is least likely to be present in a patient admitted with a history of aneurysmal SAH?
-
(a)
ECG abnormalities
-
(b)
Hyponatremia
-
(c)
Hypothermia
-
(d)
Hydrocephalus
-
(a)
-
3.
The gold standard for the detection of ruptured cerebral aneurysms in acute SAH is
-
(a)
CT
-
(b)
MRA
-
(c)
CTA
-
(d)
DSA
-
(a)
-
4.
Which of the following complications carries the highest mortality in acute SAH?
-
(a)
Rebleeding
-
(b)
Electrolyte abnormalities
-
(c)
ECG changes
-
(d)
Hyperthermia
-
(a)
-
5.
The only proven pharmacological agent which improves outcome in patients having aneurysmal SAH is
-
(a)
Magnesium
-
(b)
Clazosentan
-
(c)
Nimodipine
-
(d)
Erythropoietin
-
(a)
-
6.
Patient having aneurysmal bleed with large intraparenchymal hematoma is preferably taken up for
-
(a)
Surgical clipping
-
(b)
Coiling
-
(c)
Flow divertor placement
-
(d)
Conservative management
-
(a)
-
7.
Which one is not true about antifibrinolytics administration in SAH?
-
(a)
Delay in definitive treatment is expected
-
(b)
Prevents vasospasm
-
(c)
Should be given for <72 h
-
(d)
May cause cerebral ischemia
-
(a)
-
8.
Which one is true about seizures in SAH?
-
(a)
Prophylactic therapy should be given for 1 month.
-
(b)
Short course of anti-epileptic drugs <7 days may be considered.
-
(c)
Long-term use is associated with a good outcome.
-
(d)
Levetiracetam is proven to be better than phenytoin.
-
(a)
-
9.
Which one is a feature of neurogenic stunned myocardium?
-
(a)
Troponin levels will be higher than that in MI
-
(b)
No past history of cardiac disease
-
(c)
Wall motion abnormalities correlating with coronary vascular distribution
-
(d)
Abnormal coronaries.
-
(a)
-
10.
All are components of early brain injury except
-
(a)
Microthrombosis
-
(b)
Decreased glutamate
-
(c)
Cortical spreading depolarisation
-
(d)
High ET-1.
-
(a)
Answers: 1. (b), 2. (c), 3. (d), 4. (a), 5. (c), 6. (a), 7. (b), 8. (b), 9. (b), 10. (b).
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Mahajan, C., Kapoor, I., Prabhakar, H. (2020). Aneurysmal Subarachnoid Hemorrhage. In: Bidkar, P., Vanamoorthy, P. (eds) Acute Neuro Care. Springer, Singapore. https://doi.org/10.1007/978-981-15-4071-4_11
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DOI: https://doi.org/10.1007/978-981-15-4071-4_11
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