Subarachnoid hemorrhage a major complication ,this presentation can help you understand the disease, the signs & symptoms and give you the diagnostic feature ,I hope you well enjoy studying it ... Good luck :)

1. SUBARACHNOID
HEMORRHAGE
Dr.Rahaf Nizar AlShamali

3. BLOOD SUPPLY TO THE BRAIN

4. BLOOD SUPPLY TO THE BRAIN

5. Normal Angiogram

6. • SAH a type of:
Hemorrhagi
c
stroke

7. SPONTANEOUS SAH
causes
80%
5%
• *OTHER CAUSES: brain tumor, vasculitis , cong &blood
disorder , spinal AVM, dural sinus thrombosis , infection.
Aneurysmal
SAH

8. INTRACRANIAL ANEURYSMS
• Incidence depends on many factors like
in Japan 22/100,000
in Finland 19/100,000
in world average 9/100,000
• Main factors : Racial & genetics
• Low incidence in middle east due to genetics
& lack of reporting

9. In gender:
>
3:2
BACK

10. A CASE

11. TYPES of aneurysms(shape):
AKA sacular and congenital
•Vary in size, giant cell (size=2.5 cm )
•Produce their signs : As tumor that
affect by pressure on the adjacent
structures ophthalmic a.

12. Giant Anterior Communicating Artery
Aneurysm

13. Ophthalmic artery with berry aneurysm
back

14. TYPES of aneurysms(shape):
• : (mostly the post circulation
(basilar artery))
• atherosclerotic process , emboli &
dissection , DON’T RUPTURE.

15. fusiform
back

16. •Case seen in
clinic
Female patient came with headache>>
here angiogram shows the following :

22. back

23. TYPES of aneurysms (origin):
:result of infective process
Infective embolus emerging from bacterial endocarditis(strep &
staph. )  weaken of peripheral cerebral vessel  mycotic
aneurysm
back

24. TYPES of aneurysms (origin):
• injuries with sever basilar fractures
• Suffered bullet injuries
 traumatized vessel became weak develop
aneurysm
• ICA  develop aneurysm in the cavernous sinus
( due to basilar trauma )
 This does not produce SAH  but lead to carotid
cavernous fistula ??
back

26. CT SCAN ,Bilateral cavernous
sinus aneurysm

27. Natural history;
• Factors for aneurysms :
• Anatomical congenital defect (75% OF
CASES, the wall seem weaker than other vessel
in the body : 1.defect in elastic element (defect in tunica media &
adventitia).
*specially at the site of vessel bifurcation
add stress ( Hemodynamic stress at
bifurcation)
OTHER Risk Factors:
HTN, Atherosclerosis, smoking ,OCP, pregnancy, vigorous
exercise & hemodynamic stress

29. • Spontaneous SAH
• In adults , aneurysmal rupture present with pressure
symptoms lead to neurological manifest
• In children , rupture of AVM come with epilepsy
• Mortality And Morbidty
10-15% die immediately
10 – 15% die within first 24 h.
40% succumbed to disease in 1st
week
50% die at 6 months
40% will have permanent disability

30. Clinical Presentation :
• Vary from symptoms confused with an influenzal
disease to very sever lead to immediate die, acute
rise in ICP
• The classical triad :
HEADACHE
DECREASED LEVEL OF CONSCIOUSNESS
MENINGISM
Other symptoms :vomiting, seizures, photophobia,
drooping eye-lid, sciatica.

31. • Headache :
“the worst headache of my life” sudden, with or without other
manifestation.
• Decreased level of consciousness :
In 50% of cases. due to sudden inc. in ICP & dec. in CPP …
ischemia … coma … die
A good indicator of the severity
• Meningism :
In 75% of cases, irritation of meninges, symptoms : neck rigidity,
photophobia, vomiting, low grade of fever
In case of nerve roots irritation may cause sciatica & low back
pain.

32. • Other manifestations
• Seizures :
20% of cases due to cortex irritation not the site
of aneurysm
• Mass effect :
Due to association with intracerebral hematoma &
infarction , complicated with edema, commonly
AVM
• Neurological deficits :
Result from the effect of the mass or ischemia
• Visual manifestation :
Papilledema following the ictus or , from 6th
nerve
palsy

33. Diagnosis :
• When the patient come to the ER with the
clinical triad so it’s SAH until proven otherwise.
• Next step ?
Non-contrast CT-scan

34. Non-contrast CT-scan :
• High accuracy 95% become undetectable after 72h.
• The blood appear as white streaks in the sulci replacing the black
CSF
• Could be found in :
Parenchyma
The ventricles
Subdural space
In case of negative CT
due to
late investigation the
next step
is ????

35. Lumber Puncture (LP) :
• Positive blood in CSF from 4 hs. after SAH and
remain 14 days and later as xanthochromia
• Which is a yellowish discoloration
“spectrophotometry”
due to breakdown of RBC
& release of pigment
• Must be distinguished
from traumatic LP
by bring3-4 tubes tests
-at SAH :all homogenous
red color
-traumatic LP: not homo.