Non-traumatic Subarachnoid Hemorrhage

  • J. I. Suarez


Non-traumatic subarachnoid hemorrhage (SAH) has distinct risk factors, demographics, and treatment from other forms of stroke. Spontaneous SAH, mostly aneurysmal, accounts for about 2–5% of all strokes, afflicting 37,500 cases of stroke per year in the United States [1]. A cerebral aneurysm is an outpouching of the brain arteries that eventually ruptures. The incidence of non-traumatic aneurysmal SAH has remained stable over the past 30 years [2]. Although the incidence of non-traumatic SAH varies from region to region, the aggregate worldwide incidence is about 10.5 per 100,000 person years [3, 4]. Women have a 1.6 times (95% confidence interval [CI] 1.5–2.3) higher risk than men [5] and people of African descent a 2.1 times (95% CI 1.3–3.6) higher risk than whites [6]. The major risk factors for non-traumatic SAH include cigarette smoking, hypertension, cocaine use, and habitual heavy alcohol intake [7]. Other factors, such as a family history of first-degree relatives with the disease and heritable connective-tissue disorders, also play a role [7].


Subarachnoid Hemorrhage Intracranial Aneurysm Cerebral Vasospasm Head Compute Tomography Aneurysmal Subarachnoid Hemorrhage 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Mayberg MR, Batjer HH, Dacey R, et al (1994) Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 25:2315–2328PubMedGoogle Scholar
  2. 2.
    van Gijn J, Rinkel JE (2001) Subarachnoid haemorrhage: diagnosis, causes and management. Brain 124:249–278CrossRefPubMedGoogle Scholar
  3. 3.
    Linn FH, Rinkel GJ, Algra A, van Gijn J (1996) Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke 27:625–629PubMedGoogle Scholar
  4. 4.
    Suarez JI, Tarr RW, Selman WR (2006) Aneurysmal subarachnoid hemorrhage. N Engl J Med 354:387–396CrossRefPubMedGoogle Scholar
  5. 5.
    Lindsay KW, Teasdale GM, Knill-Jones RP (1983) Observer variability in assessing the clinical features of subarachnoid hemorrhage. J Neurosurg 58:57–62PubMedGoogle Scholar
  6. 6.
    Broderick JP, Brott T, Tomsick T, Huster G, Miller R (1992) The risk of subarachnoid hemorrhage and intracerebral hemorrhages in blacks as compared to whites. N Engl J Med 326: 733–736PubMedCrossRefGoogle Scholar
  7. 7.
    Hop JW, Rinkel GJ, Algra A, van Gijn J (1997) Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke 28:660–664PubMedGoogle Scholar
  8. 8.
    Roos YBWEM, Dijkgraaf MGW, Albrecht KW, et al (2002) Direct costs of modern treatment of aneurysmal subarachnoid hemorrhage in the first year after diagnosis. Stroke 33:1595–1599CrossRefPubMedGoogle Scholar
  9. 9.
    Edlow JA, Caplan LR (2000) Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 342:29–36CrossRefPubMedGoogle Scholar
  10. 10.
    Polmear A (2003) Sentinel headaches in aneurismal subarachnoid hemorrhage: what is the true incidence? A systematic review. Cephalalgia 23:935–941CrossRefPubMedGoogle Scholar
  11. 11.
    Botterell EH, Lougheed WM, Scott JW, Vanderwater SL (1956) Hypothermia and interruption of carotid and vertebral circulation in the surgical management of intracranial aneurysms. J Neurosurg 13:1–42PubMedGoogle Scholar
  12. 12.
    Hunt WE, Hess RM (1968) Surgical risk as related to time intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20PubMedGoogle Scholar
  13. 13.
    Drake CG (1968) Report of World Federation of Neurological Surgeons (committee on a universal subarachnoid hemorrhage grading scale (Neurosurgical forum). J Neurosurg 68:985–986Google Scholar
  14. 14.
    Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computed tomographic scanning. Neurosurgery 6:1–9CrossRefPubMedGoogle Scholar
  15. 15.
    Claassen J, Bernardini GL, Kreiter K, et al (2001) Effect of cisternal and ventricular blood on risk pf delayed cerebral ischemia after subarachnoid hemorrhage. The Fisher Scale revisited. Stroke 32:2012–2020CrossRefPubMedGoogle Scholar
  16. 16.
    Hijdra A, Vermeulen M, van Gijn J, van Crevel H (1987) Rerupture of intracranial aneurysms: a clinicoanatomic study. J Neurosurg 67:29–33PubMedGoogle Scholar
  17. 17.
    Locksley HB (1966) Natural history of subarachnoid hemorrhage, intracranial aneurysms, and arteriovenous malformations. J Neurosurg 25:321–368PubMedCrossRefGoogle Scholar
  18. 18.
    Hijdra A, van Gijn J, Nagelkerke NJD, Vermeulen M, van Crevel H (1988) Prediction of delayed cerebral ischemia, rebleeding, and outcome after aneurysmal subarachnoid hemorrhage. Stroke 19:1250–1256PubMedGoogle Scholar
  19. 19.
    Chyatte D, Fode NC, Sundt TM (1988) Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg 69:326–331PubMedCrossRefGoogle Scholar
  20. 20.
    Haley EC, Kassell NF, Torner JC (1992) The International Cooperative Study on the timing of aneurysm surgery. The North American experience. Stroke 23:205–214PubMedGoogle Scholar
  21. 21.
    Kassell NF, Torner JC, Haley EC, et al (1990) The International Cooperative Study on the timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 73:18–36PubMedGoogle Scholar
  22. 22.
    Kassell NF, Torner JC, Jane JA, Haley EC, Adams HP (1990) The International Cooperative Study on the timing of aneurysm surgery. Part 2; surgical results. J Neurosurg 73:37–47PubMedCrossRefGoogle Scholar
  23. 23.
    Solenski N, Haley EC, Kassell NF, et al (1995) Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Crit Care Med 23:1007–1017CrossRefPubMedGoogle Scholar
  24. 24.
    van Gijn J, Hijdra A, Widjicks EFM, Vermeulen M, van Crevel H (1985) Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg 63:355–362PubMedGoogle Scholar
  25. 25.
    Hijdra A, van Gijn J, Stefanko S, van Dongen KJ, Vermeulen M, van Crevel H (1986) Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: clinicoanatomic correlations. Neurology 36:329–333PubMedGoogle Scholar
  26. 26.
    Mayberg MR, Batjer HH, Dacey R, et al (1994) Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 25:2315–2328PubMedGoogle Scholar
  27. 27.
    Heros RC, Zervas NT, Varsos V (1983) Cerebral vasospasm after subarachnoid hemorrhage: an update. Ann Neurol 14:599–608CrossRefPubMedGoogle Scholar
  28. 28.
    Fletcher TM, Taveras JM, Pool JL (1959) Cerebral vasospasm in angiography for intracranial aneurysms: incidence and significance in one hundred consecutive angiograms. Arch Neurol 1:38–47PubMedGoogle Scholar
  29. 29.
    Graf C, Nibbelink DW (1974) Cooperative study of intracranail aneurysms and subarachnoid hemorrhage. Stroke 5:559–601Google Scholar
  30. 30.
    Haley EC, Kassell NF, Torner JC (1993) A randomized trial of nicardipine in subarachnoid hemorrhage: angiographic and transcranial Doppler ultrasound results. J Neurosurg 78:548–553PubMedGoogle Scholar
  31. 31.
    Suarez JI, Qureshi AI, Yahia AB, et al (2002) Symptomatic vasospasm diagnosis after subarachnoid hemorrhage: evaluation of transcranial Doppler ultrasound and cerebral angiogrpahy as related to the compromised vascular distribution. Crit Care Med 30:1348–1355CrossRefPubMedGoogle Scholar
  32. 32.
    Awad IA, Carter PL, Spetzler RF, Medina M, Willaims FW (1987) Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilution and arterial hypertension. Stroke 18:365–372PubMedGoogle Scholar
  33. 33.
    Kassell NF, Peerles SJ, Durward QJ, Beck DW, Drake CG, Adams HP (1982) Treatment of ischemic deficits from vasospasm with intravascular volume expansion and induced arterial hypertension. Neurosurgery 11:337–343CrossRefPubMedGoogle Scholar
  34. 34.
    Muizelaar JP, Becker DP (1986) Induced hypertension for the treatment of cerebral ischemia after subarachnoid hemorrhage. Surg Neurol 25:317–325CrossRefPubMedGoogle Scholar
  35. 35.
    Amin-Hanjani S, Schwartz RB, Sathi S, Stieg PE (1999) Hypertensive encephalopathy as a complication of hyperdynamic therapy for vasospasm: report of two cases. Neurosurgery 44:1113–1116CrossRefPubMedGoogle Scholar
  36. 36.
    Fandino J, Kaku Y, Schuknecht B, Valvanis A, Yonekawa Y (1998) Improvement of cerebral oxygenation patterns and metabolic validation of superselective intraarterial infusion of papaverine for the treatment of cerebral vasospasm. J Neurosurg 89:93–100PubMedCrossRefGoogle Scholar
  37. 37.
    Higashida RT, Halbach VV, Cahan LD, et al (1989) Transluminal angioplasty for treatment of intracranial arterial vasospasm. J Neurosurg 71:648–653PubMedGoogle Scholar
  38. 38.
    Kaku Y, Yonekawa Y, Tsukahara T, Kazekawa K (1992) Superselective intra-arterial infusion of papaverine for the treatment of cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg 77:842–847PubMedCrossRefGoogle Scholar
  39. 39.
    Newell DW, Eskridge JM, Mayberg MR, Grady MS, Winn HR (1989) Angioplasty for the treatment of symptomatic vasospasm following subarachnoid hemorrhage. J Neurosurg 71:654–660PubMedCrossRefGoogle Scholar
  40. 40.
    Dietrich HH, Dacey RG (2000) Molecular keys to the problems of cerebral vasospasm. Neurosurgery 46:517–530CrossRefPubMedGoogle Scholar
  41. 41.
    Macdonald RL (2001) Pathophysiology and molecular genetics of vasospasm. Acta Neurochir S77:7–11Google Scholar
  42. 42.
    Gabikian P, Clatterbuck RE, Eberhart CG, Tyler BM, Tierney TS, Tamargo RJ (2002) Prevention of experimental cerebral vasospasm by intracranial delivery of a nitric oxide donor from a controlled-release polymer: toxicity and efficacy studies in rabbits and rats. Stroke 33:2681–2686CrossRefPubMedGoogle Scholar
  43. 43.
    Juvela S (2002) Plasma endothelin and big endothelin concentrations and serum endothelin-converting enzyme activity following aneurismal subarachnoid hemorrhage. J Neurosurg 97:1287–1293PubMedGoogle Scholar
  44. 44.
    McGirt MJ, Lynch JR, Parra A, et al (2002) Simvastatin increases endothelial nitric oxide synthase and ameliorates cerebral vasospasm resulting from subarachnoid hemorrhage. Stroke 33:2950–2956CrossRefPubMedGoogle Scholar
  45. 45.
    Pilitsis JG, Coplin WM, O’Regan MH, et al (2002) Free fatty acids in human cerebrospinal fluid following subarachnoid hemorrhage and their potential role in vasospasm: a preliminary observation. J Neurosurg 97:272–279PubMedCrossRefGoogle Scholar
  46. 46.
    Vatter H, Mursch K, Zimmerman M, et al (2002) Endothelin-converting enzyme activity in human cerebral circulation. Neurosurgery 51:445–451CrossRefPubMedGoogle Scholar
  47. 47.
    Zuccarello M (2001) Endothelin: the “prime suspect” in cerebral vasospasm. Acta Neurochir S77:61–65Google Scholar
  48. 48.
    Bulter WE, Peterson JW, Zervas NT, Morgan KG (1996) Intracellular calcium, myosin light chain phosphorylation, and contractile force in experimental cerebral vasospasm. Neurosurgery 38:781–788PubMedGoogle Scholar
  49. 49.
    Koide M, Nishizawa S, Ohta S, Yokoyama T, Namba H (2002) Chronological changes of the contractile mechanism in prolonged vasospasm after subarachnoid hemorrhage: from protein kinase C to protein tyrosine kinase. Neurosurgery 51:1468–1476CrossRefPubMedGoogle Scholar
  50. 50.
    Laher I, Zhang JH (2001) Protein kinase C and cerebral vasospasm. J Cereb Blood Flow 21:887–906CrossRefGoogle Scholar
  51. 51.
    Clatterbuck RE, Oshiro EM, Hoffman PA, Dietsch GN, Pardoli DM, Tamargo RJ (2002) Inhibition of vasospasm with lymphocyte function-associated antigen-1 monoclonal antibody in a femoral artery model in rats. J Neurosurg 97:676–682PubMedCrossRefGoogle Scholar
  52. 52.
    Mocco J, Mack WJ, Kim GH, et al (2002). Rise in serum soluble intercellular adhesion molecule-1 levels with vasospasm following aneurismal subarachnoid hemorrhage. J Neurosurg 97:537–541PubMedGoogle Scholar
  53. 53.
    Sercombe R, Dinh YR, Gomis P (2002) Cerebrovascular inflammation following subarachnoid hemorrhage. Jpn J Pharmacol 88:227–249CrossRefPubMedGoogle Scholar
  54. 54.
    Thai QA, Oshiro EM, Tamargo RJ (1999) Inhibition of experimental vasospam in rats with the periadventitial administration of ibuprofen using controlled-release polymers. Stroke 30:140–147PubMedGoogle Scholar
  55. 55.
    Borel CO, McKee A, Parra A, et al (2003) Possible role for vascular cell proliferation in cerebral vasospasm after subarachnoid hemorrhage. Stroke 34:427–433CrossRefPubMedGoogle Scholar
  56. 56.
    McGirt MJ, Lynch JR, Blessing R, et al (2002) Serum von Willebrand factor, matrix metallo-proteinase-9, and vascular-endothelial growth factor levels predict the onset of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurgery 51:1128–1135CrossRefPubMedGoogle Scholar
  57. 57.
    Ono S, Komuro T, Macdonald LR (2002) Heme oxygenase-1 gene therapy for prevention of vasospasm in rats. J Neurosurg 96:1094–1102PubMedGoogle Scholar
  58. 58.
    Auer LM (1984) Acute operation and preventive nimodipine improve outcome in patients with ruptured cerebral aneurysms. Neurosurgery 15:57–66CrossRefPubMedGoogle Scholar
  59. 59.
    Flamm ES, Adams HP, Beck DW, et al (1988) Dose-escalation study of intravenous nicardipine in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 68:393–400PubMedCrossRefGoogle Scholar
  60. 60.
    Gilsbach JM, Reulen HJ, Ljunggren B, et al (1990) Early aneurysm surgery and preventive therapy with intravenously administered nimodipine: a multicenter, double-blind, dose-comparison study. Neurosurgery 26:458–464CrossRefPubMedGoogle Scholar
  61. 61.
    Petruk KC, West M, Mohr G, et al (1988) Nimodipine treatment in poor-grade aneurysm patients. J Neurosurg 68:505–517PubMedGoogle Scholar
  62. 62.
    Pickard JD, Murray GD, Illingworth R, et al (1989) Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid hemorrhage: British aneurysm nimodipine trial. BMJ 298:636–642PubMedCrossRefGoogle Scholar
  63. 63.
    Rinkel GJ, Feigin VL, Algra A, Vermeulen M, van Gijn J (2004) Calcium antagonists for aneurysmal subarachnoid hemorrhage. Cochrane Database Syst Rev 4:CD000277Google Scholar
  64. 64.
    Kassell NF, Haley EC, Apperson-Hansen C, Alves WM (1996) Randomized, double-blind, vehicle-controlled trial of tirilazad mesylate in patients with aneurysmal subarachnoid hemorrhage: a cooperative study in Europe, Australia, and New Zealand. J Neurosurg 84: 221–228PubMedGoogle Scholar
  65. 65.
    Lanzino G, Kassell NF (1999) Double-blind, randomized, vehicle-controlled study of high-dose tirilazad mesylate in women with aneurysmal subarachnoid hemorrhage. Part II. A cooperative study in North America. J Neurosurg 90:1018–1024PubMedGoogle Scholar
  66. 66.
    Asano T, Takakura K, Sano K, et al (1996) Effects of hydroxyl radical scavenger on delayed ischemic neurological deficits following aneurysmal subarachnoid hemorrhage: results of a multicenter, placebo-controlled double-blind trial. J Neurosurg 84:792–803PubMedGoogle Scholar
  67. 67.
    Saito I, Asano T, Sano K, et al (1998) Neuroprotective effect of an antioxidant, ebselen, in patients with delayed neurological deficits after aneurysmal subarachnoid hemorrhage. Neurosurgery 42:269–277CrossRefPubMedGoogle Scholar
  68. 68.
    Mendelow AD, Stockdill G, Steers AJ, Hayes J, Gilligham FJ (1982) Double-blind trial of aspirin in patients receiving tranexamic acid for subarachnoid hemorrhage. Acta Neurochir (Wien) 62:195–202CrossRefGoogle Scholar
  69. 69.
    Shaw MD, Foy PM, Conway M, et al (1985) Dipyridamole and postoperative ischemic deficits in aneurysmal subarachnoid hemorrhage. J Neurosurg 63:699–703PubMedGoogle Scholar
  70. 70.
    Saito I, Asano T, Ochiai C, Takakura K, Tamura A, Sano K (1983) A double-blind clinical evaluation of the effect of Nizofenone (Y-9179) on delayed ischemic neurological deficits following aneurysmal rupture. Neurol Res 5:29–47PubMedGoogle Scholar
  71. 71.
    Tokiyoshi K, Ohnishi T, Nii Y (1991) Efficacy and toxicity of thromboxane synthetase inhibitor for cerebral vasospasm after subarachnoid hemorrhage. Surg Neurol 36:112–118CrossRefPubMedGoogle Scholar
  72. 72.
    Suzuki S, Sano K, Handa H, et al (1989) Clinical study of OKY-046, a thromboxane synthetase inhibitor, in prevention of cerebral vasospasms and delayed cerebral ischemic symptoms after subarachnoid hemorrhage due to aneurysmal rupture: a randomized, double-blind study. Neurol Res 11:79–88PubMedGoogle Scholar
  73. 73.
    Veyna RS, Seyfried D, Burke D, et al (2002) Magnesium sulfate therapy for aneurysmal subarachnoid hemorrhage. J Neurosurg 96:510–514PubMedGoogle Scholar
  74. 74.
    Egge A, Waterloo K, Sjoholm H, Solberg T, Ingebrigten T, Romner B (2001) Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery 49:593–606CrossRefPubMedGoogle Scholar
  75. 75.
    Lennihan L, Mayer SA, Fink ME, et al (2000) Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke 2000;31:383–391Google Scholar
  76. 76.
    Mayer SA, Solomon RA, Fink ME, et al (1998) Effect of 5% albumin solution on sodium balance and blood volume after subarachnoid hemorrhage. Neurosurgery 42:759–768CrossRefPubMedGoogle Scholar
  77. 77.
    Nakagawa A, Su CC, Sato K, Shirane R (2002) Evaluation of changes in circulating blood volume during acute and very acute stages of subarachnoid hemorrhage: implications for the management of hypovolemia. J Neurosurg 97:268–271PubMedGoogle Scholar
  78. 78.
    Muizelaar JP, Zwienenberg M, Rudisill NA, Hecht ST (1999) The prophylactic use of transluminal balloon angioplasty in patients with Fischer grade 3 subarachnoid hemorrhage: a pilot. J Neurosurg 91:51–58PubMedGoogle Scholar
  79. 79.
    Suarez JI, Shannon L, Zaidat OO, et al (2004) Effect of human albumin administration on clinical outcome and hospital cost in patients with SAH. J Neurosurg 100:585–90PubMedGoogle Scholar
  80. 80.
    Treatment of subarachnoid hemorrhage with human albumin. NCT 00283400. At: Accessed Dec 2006
  81. 81.
    Guglielmi G, Vinuela F, Dion J, Duckweiler G (1991) Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: preliminary clinical experience. J Neurosurg 75: 8–14PubMedGoogle Scholar
  82. 82.
    Molyneux A, Kerr R, Stratton I, et al (2002) International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274CrossRefPubMedGoogle Scholar
  83. 83.
    Molyneux AJ, Kerr RSC, Yu LM, et al (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809–817CrossRefPubMedGoogle Scholar
  84. 84.
    Britz GW (2005) ISAT Trial: coiling or clipping for intracranial aneurysms?. Lancet 366:783–785CrossRefPubMedGoogle Scholar
  85. 85.
    Johnston CS, Higashida RT, Barrow DL, et al (2002) Recommendations for the endovascular treatment of intracranaila aneurysms. A Statement for Healthcare Professionals fro the Committee on Cerebrovascular Imaging of the American Heart Association Council on Cardiovascular Radiology. Stroke 33:2536–2544CrossRefPubMedGoogle Scholar
  86. 86.
    Lozier AP, Connolly ES Jr, Lavine SD, Solomon RA (2002) Guglielmi detachable coil emboli-zation of posterior circulation aneurysms. A systematic review of the literature. Stroke 33:2509–2518CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2007

Authors and Affiliations

  • J. I. Suarez
    • 1
  1. 1.Department of NeurologyUniversity Hospitals Case Medical CenterClevelandUSA

Personalised recommendations