Vascular
Numbers
- Incidence: 8/100,000
- 2% has aneurysm
- Peak age: 60 yrs
- 20% cases occur <45
- F:M ; 3:2
- 30% occur during sleep; ICH occurs during wake
- 50% have warning S&S 6-20 days prior to SAH
- H/A is lateralizing in 30% only
- SAH + ICH: 30%
- SAH + IVH: 20%
- SAH + SDH:@ 5%
- Due to
- PCOM when over convexity
- Distal ACA aneurysm with interhemispheric subdural
- Poor grade (WFNS >=3)
- 30% of all admissions
- 2/3 of patients who have undergone successful aneurysm clipping never return to their premorbid quality of life, despite the majority of patients surviving with Glasgow Outcome Scores of 4 or 5.
- 65% die from 1st SAH
- 46% will fully recover, if there is no neurology at rupture
- 60% only return to their formal jobs Alkhindi 2010
Aetiology SAH
- Traumatic: Most common
- Cerebral artery dissection
- Carotid
- Vertebral: can cause 3rd/4th intraventricular bleed
- Spontaneous:
- Ruptured aneurysm 80%
- Cerebral AVM 5%
- CNS vasculitides
- Tumour (Rare)
- Rupture of an infundibulum
- Criteria:
- Triangular in shape
- Mouth <3mm
- Vessel at apex
- Conical outpouching from an artery
- Conical in shape (see pic) —> Does not have a neck
- Most common in origin of PCOM (ICA side)
- Low risk of rupture
- Rare but have been shown to progress to aneurysm
- Treatment:
- If it is a source of bleeding can be managed with
- Wrapping
- Placing encircling clip
- Sacrificing artery if can be done
- Coagulation disorders
- Iatrogenic
- Thrombocytopenia
- Dural sinus thrombosis
- Spinal AVM
- Pretruncal non aneurysmal SAH (aka Perimesencephalic bleed)
- New name because imaging shows that it localised inform of the brainstem (truncus cerebri) centre in front of pons rather than perimesencephalic (around midbrain)
- Drugs: cocaine
- Sickle cell anaemia
- Pituitary apoplexy
- No cause found in 15%
Risk factors
- HTN
- BP variation during the day
- Oral contraceptives
- Substance abuse
- Smoking: not associated with ICH
- Cocaine
- Alcohol: controversial for SAH but high with ICH
- Pregnancy and while giving birth
- No real evidence that straining increases the risk of an aneurysm rupturing
- Slight inc. risk during LP and or cerebral angiography in pt with aneurysm
Bleeding risk diseases
DSA+ SAH | Untreated | 20% 1st 14 days, 50% 1st 6 months | 3%/yr (after the 6 months | |
DSA+ SAH | Clipped | 1.0%/yr (for first year) | 0.4%/17.6years | ISAT 1; ISAT 10 |
DSA+ SAH | Coil | 2.6%/yr (for first year) | 1.6%/17.6 years | ISAT 1; ISAT 10 |
DSA- SAH | 0.5%/yr | ?? Greenberg | ||
Unruptured aneurysm | 1.0%/yr | ISUIA |
From Greenberg
Summary of rebleeding, complete occlusion, and retreatment rates as a function of treatment modality (clip vs. coil) for the 4 randomized controlled trials
ㅤ | Rebleedᵃ: Clip | Rebleedᵃ: Coil | Complete occlusion: Clip | Complete occlusion: Coil | Retreatment: Clip | Retreatment: Coil |
Finnish | 0% | 0% | 73.7%ᵇ | 50%ᵇ | 7% | 23.1% |
ISAT | 1.0% | 2.6% | 82% | 66% | 4.2% | 15.1% |
ISAT₅ᶜ | 0.3%* | 0.9%* | n/a | n/a | — | — |
ISAT₁₀ᶜ | 0.4% | 1.6% | n/a | n/a | — | — |
Chinese | 3.3% | 3.2% | 83.7%* | 64.9%* | — | — |
BRATᵈ | 0.8%ᵉ | 0% | 85% | 58% | 4.5%* | 10.6%* |
BRAT₃ᵈ | 0% | 0% | 87% | 52% | 5%* | 13%* |
- *statistically significant difference (p<0.05)
- ᵃRebleeding from target aneurysm after first procedure
- ᵇResult achieved after treatment during first hospitalization
- ᶜISAT₅ & ISAT₁₀ refer to the 5- and 10-year follow-up studies. Rebleeding results for these studies refer to recurrent SAH after the 1st year of follow-up
- ᵈBRAT₃ refers to the 3-year follow-up study. BRAT & BRAT₃ are “as-treated” results
- ᵉBoth rebleeding events occurred during the initial hospitalization
ISUIA 1 (Retrospective)
Yearly rupture risk for patients with unruptured intracranial aneurysms
Aneurysms size (mm) | Risk of rupture/y with no previous bleed | Risk of rupture/y with previous bleed |
0-10 | 0.05% | 0.5% |
10-24 | <1% | <1% |
>24 | 6% | ㅤ |
Clinical features of SAH
- NCEPOD audit 2013 mis diagnosis
- 43% primary care
- 13% secondary care
- General
- Headache
- Sentinel h/a: 50%
- Due to
- Bleeding in SAH: easily seen on CT
- Bleeding into aneurysm wall
- Enlargement of aneurysm
- Only last for a day
- Other differentials for h/a
- Never make a diagnosis of new onset migraine w/o r/o SAH
- Diagnostic criteria for idiopathic thunderclap headache
- Very severe pain intensity
- Instantaneous or hyperacute onset of pain (<30 seconds)
- Appropriate investigations exclude the presence of an underlying cause. These include subarachnoid haemorrhage, cerebral venous sinus thrombosis, pituitary apoplexy, arterial dissection, spontaneous intracranial hypotension, and acute hypertensive crisis.
- Severe global h/a with sudden onset (max intensity in 1 min)
- 50% has vomiting
- Clinically undifferentiable from SAH
- Perform LP and CT to r/o SAH
- No need to perform DSA
- Diagnostic criteria for reversible cerebral vasoconstriction syndrome
- Acute and severe headache (often thunderclap) with or without focal deficits or seizures
- Uniphasic course without new symptoms more than 1 month after clinical onset
- Segmental vasoconstriction of cerebral arteries shown by indirect (eg, magnetic resonance or CT) or direct catheter angiography
- No evidence of aneurysmal subarachnoid haemorrhage
- Normal or near-normal CSF (protein concentrations <100 mg/dL, <15 white blood cells per μL)
- Complete or substantial normalisation of arteries shown by follow-up indirect or direct angiography within 12 weeks of clinical onset
- Severe h/a
- Paroxysmal onset
- +/- neurological deficit
- String of beads appearance on angiography
- Clears in 1-3 months
- Associated with
- Drug use: cocaine, marijuana, nasal decongestants, ergot derivatives, SSRIs, interferon, nicotine patches
- Binge drinking
- Postpartum
- Severe throbbing sometimes explosive H/A with onset just before or at time of orgasm
- Different front pre-orgasmic headache: intensifies with sexual arousal
- No neurological deficit
- No radiological deficit
- Need to do CT and LP to r/o SAH
- No need for DSA
Benign/idiopathic thunderclap h/a (BTH) (aka crash migraine)
Comment
Idiopathic thunderclap headaches may occur spontaneously or may be precipitated by the Valsalva manoeuvre, sexual activity, strenuous exercise, or exertion. Headaches may recur over a 7–14 day period. Similar headaches may occur infrequently over subsequent months to years. Investigations are always necessary to rule out secondary causes listed in 3. If performed, angiography may demonstrate diffuse segmental cerebral vasospasm, which resolves within weeks to months.
Modified from Dodick et al.¹⁵ By permission of Cephalalgia.
Reversible cerebral vasoconstriction syndrome (RCVS)- AKA benign cerebral angiopathy/vasculitis
Adapted from the International Headache Society criteria for acute reversible cerebral angiopathy and the criteria proposed in 2007 by Calabrese and coworkers².
Benign orgasmic cephalgia
Feature | BTH | RCVS | BOC |
Focal neurology | No | Yes/No | No |
Radiological | None | String of beads (vasoconstriction) | None |
Trigger | None | Drug use/binge EtOH/post-partum | Orgasm |
Treatment | CT + LP | CT+ LP + symptomatic management | CT + LP |
Self limiting | Yes | Yes | Yes |
- Vomit
- Syncope
- Neck pain (meningismus)
- Nuchal rigidity to flexion within 24hrs
- Has association with inc. mortality in Hunt and Hess study
- + Kernig sign: flex thigh to 90 degrees with knee bent then straighten knee causes pain in hamstrings
- Brudzinski sign: flex pt neck causes involuntary hip flexion
- Photophobia
- LOC w/ subsequent recovery
- Coma: due to
- Inc. ICP
- Damaged to brain parenchyma from parenchymal haemorrhage
- Hydrocephalus
- Diffuse ischaemia
- Seizure: post ictal
- Dec. CDF: neurogenic cardiac depression —> reduce CO
- Ocular haemorrhage:
- Occur in 30% of pt with SAH
- SAH —> compression of central retinal vein + retina choroidal anastomoses by elevated CSF pressure —> venous hypertension —> rupture of retinal venules
- NOT due to blood leaking intracranially to the eye
- Three types
- Preretinal: Subhyaloid haemorrhage
- Associated with higher mortality
- 15% of SAH
- Intra-retinal
- Vitreous humour haemorrhage (tearson syndrome):
- 15% of SAH
- Usually bilateral
- Develops early but can present as late as 12 days post SAH
- Associated with higher mortality
- Treatment
- Require close monitoring with ophthalmology for
- Elevated intraocular pressure
- Retinal membrane formation —> retinal detachment
- Retinal fold
- Most cases clear spontaneous
- Vitrectomy if vision not improving
- Longer term prognosis good: 80% recover vision
Features | Pre-retinal (subhyaloid) haemorrhage | Intra-retinal haemorrhage | Vitreous humor haemorrhage (tearson syndrome) |
Location | Between retina and vitreous humor | Within retina | Within vitreous humor |
Obscure retinal vessels | Yes | No | Yes |
Higher mortality | Yes | Yes |
- Local neurological
- CN3 palsy: aneurysm compression —> Diplopia and ptosis
- Optic nerve: ophthalmic artery aneurysm
- Trigeminal nerve: Which artery ?
- Pain
- Low back pain: standing —> blood in CSF flow down to back —> Lumbar nerve root irritation
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