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[7][8].
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[1][2].
Nausea and vomiting Patient will develop nausea and vomiting following leaking of the blood causing irritation and with increase intracranial pressure[3][4].
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[7][8].
confusion, irritability, drowsiness or coma for few days Minor leak of blood from few days will present as these symptoms[9].
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[5][6].
visual problems Visual problems like double vision (with Oculomotor nerve palsy), sudden loss of vision, blurring can be seen[10][11].
pain on retraction/ stiffness of the neck and back, photophobia Meningeal irritation with leaked blood will causes symptoms of meningism[12][13].
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[14][15].
Past medical history of diagnosed aneurysms patient diagnosed with aneurysms are at higher risk of developing Sub Arachnoid hemorrhage[16][17].
Recent history of trauma to head Trauma can induce Sub Arachnoid hemorrhage with rupture of blood vessels/ aneurysm[18][19].
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[20][21].
past medical history of bleeding diathesis Excessive bleeding tendency will mimic the bleeding even with minor blood vessel damage[22][23].
Past medical history of hypertension (high blood pressure) and dyslipidaemia. These are acquired risk factors for development of aneurysms and rupture[24][25].
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[26][27].
History of smoking and drug abuse These are also risk factors for weakening the vessel wall increasing risk of developing Sub Arachnoid hemorrhage[28][29].
Drug history of anticoagulation Drugs like waferin, enoxaparin and increases the bleeding tendency[30].
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[31].
History of diagnosed conditions like Systemic lupus erythematosus Systemic lupus erythematosus like diseases causing vascuitis can induce rupture of blood vessels[30][31].
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[32][39][40].
history of systemic/ cerebral Infections with bacterial/ fungal Bacterial/ fungal infection in vessel wall may leads to weaken the vessel wall formation of aneurysms[33][34].
Family history of similer disease condition/ strokes There is genetics susceptibility to develop subarachnoid hemorrhage[32][35].
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[36].
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[37][38].
References
  1. DODICK D. Thunderclap headache J Neurol Neurosurg Psychiatry [online] 2002 Jan, 72(1):6-11 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.72.1.6
  2. DAVENPORT R. ACUTE HEADACHE IN THE EMERGENCY DEPARTMENT J Neurol Neurosurg Psychiatry [online] 2002 Jun, 72(Suppl 2):ii33-ii37 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.72.suppl_2.ii33
  3. BARBOZA MA, MAUD A, RODRIGUEZ GJ. Reversible cerebral vasoconstriction syndrome and nonaneurysmal subarachnoid hemorrhage J Vasc Interv Neurol [online] 2014 Jun, 7(2):17-20 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132938
  4. PEREIRA JL, DE ALBUQUERQUE LA, BORGO MC, JUNIOR GV, CHRISTO PP, DE CARVALHO GT. Choreoathetosis after subarachnoid hemorrhage related to an aneurysm of the posterior fossa Clinics (Sao Paulo) [online] 2011 Sep, 66(9):1655-1657 [viewed 22 October 2014] Available from: doi:10.1590/S1807-59322011000900026
  5. KANNER AM. Subarachnoid Hemorrhage as a Cause of Epilepsy Epilepsy Curr [online] 2003 May, 3(3):101-102 [viewed 22 October 2014] Available from: doi:10.1046/j.1535-7597.2003.03310.x
  6. CHOI KS, CHUN HJ, YI HJ, KO Y, KIM YS, KIM JM. Seizures and Epilepsy following Aneurysmal Subarachnoid Hemorrhage : Incidence and Risk Factors J Korean Neurosurg Soc [online] 2009 Aug, 46(2):93-98 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2009.46.2.93
  7. PERRY JJ, STIELL IG, SIVILOTTI ML, BULLARD MJ, LEE JS, EISENHAUER M, SYMINGTON C, MORTENSEN M, SUTHERLAND J, LESIUK H, WELLS GA. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study BMJ [online] 2010:c5204 [viewed 22 October 2014] Available from: doi:10.1136/bmj.c5204
  8. AL-SHAHI R, WHITE PM, DAVENPORT RJ, LINDSAY KW. Subarachnoid haemorrhage BMJ [online] 2006 Jul 29, 333(7561):235-240 [viewed 22 October 2014] Available from: doi:10.1136/bmj.333.7561.235
  9. MCCREA HJ, PERRINE K, NIOGI S, HäRTL R. Concussion in Sports Sports Health [online] 2013 Mar, 5(2):160-164 [viewed 22 October 2014] Available from: doi:10.1177/1941738112462203
  10. CEBULLA CM, MINNING C, PRATT C, LUBOW M. Charles Bonnet syndrome and Terson's syndrome from subarachnoid hemorrhage: good news from bad news Graefes Arch Clin Exp Ophthalmol [online] 2013 Mar, 251(3):1021-1022 [viewed 22 October 2014] Available from: doi:10.1007/s00417-012-2040-6
  11. PARK JH, PARK SK, KIM TH, SHIN JJ, SHIN HS, HWANG YS. Anterior Communicating Artery Aneurysm Related to Visual Symptoms J Korean Neurosurg Soc [online] 2009 Sep, 46(3):232-238 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2009.46.3.232
  12. DUNCOMBE AS, KENNEDY PG. Spinal subarachnoid haemorrhage presenting as spinal block without meningism. Postgrad Med J [online] 1985 Nov, 61(721):991-993 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2418485
  13. BELLOSO WH, ROMANO M, GRECO GS, DAVEY RT, PERELSZTEIN AG, SáNCHEZ ML, AJZENSZLOS MR, OTEGUI IM. Recurrent Meningitis and Subarachnoid Hemorrhage Due to Salmonella in an HIV+ Patient: Case Report and Mini-Review of the Literature Open AIDS J [online] :62-66 [viewed 22 October 2014] Available from: doi:10.2174/1874613601105010062
  14. ROOS Y, DE HAAN RJ, BEENEN L, GROEN R, ALBRECHT K, VERMEULEN M. Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in The Netherlands J Neurol Neurosurg Psychiatry [online] 2000 Mar, 68(3):337-341 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.68.3.337
  15. KUNDRA S, MAHENDRU V, GUPTA V, CHOUDHARY AK. Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage J Anaesthesiol Clin Pharmacol [online] 2014, 30(3):328-337 [viewed 22 October 2014] Available from: doi:10.4103/0970-9185.137261
  16. SACIRI B, KOS N. Aneurysmal subarachnoid haemorrhage: outcomes of early rehabilitation after surgical repair of ruptured intracranial aneurysms J Neurol Neurosurg Psychiatry [online] 2002 Mar, 72(3):334-337 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.72.3.334
  17. ROSS N, HUTCHINSON P, SEELEY H, KIRKPATRICK P. Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study J Neurol Neurosurg Psychiatry [online] 2002 Apr, 72(4):480-484 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.72.4.480
  18. ARMIN SS, COLOHAN AR, ZHANG JH. Vasospasm in traumatic brain injury Acta Neurochir Suppl [online] 2008 Aug 1, 104(13):421-425 [viewed 22 October 2014] Available from: doi:10.1007/978-3-211-75718-5
  19. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 22 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  20. SCHON F, MARSHALL J. Subarachnoid haemorrhage in identical twins. J Neurol Neurosurg Psychiatry [online] 1984 Jan, 47(1):81-83 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1027647
  21. KULKARNI RR, ADDAGADDE PV. Organic Depression and Terson's Syndrome in Adult Polycystic Kidney Disease: Case Report and Review of Literature Indian J Psychol Med [online] 2014, 36(1):94-97 [viewed 22 October 2014] Available from: doi:10.4103/0253-7176.127267
  22. KIM JS, LEE SH. Spontaneous Spinal Subarachnoid Hemorrhage with Spontaneous Resolution J Korean Neurosurg Soc [online] 2009 Apr, 45(4):253-255 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2009.45.4.253
  23. ALEXANDER M, PATIL AK, MATHEW V, SIVADASAN A, CHACKO G, MANI SE. Recurrent craniospinal subarachnoid hemorrhage in cerebral amyloid angiopathy Ann Indian Acad Neurol [online] 2013, 16(1):97-99 [viewed 22 October 2014] Available from: doi:10.4103/0972-2327.107712
  24. SAHNI R, WEINBERGER J. Management of intracerebral hemorrhage Vasc Health Risk Manag [online] 2007 Oct, 3(5):701-709 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314
  25. SASANI M, YAZGAN B, CELEBI I, AYTAN N, CATALGOL B, OKTENOGLU T, KANER T, OZER NK, OZER AF. Hypercholesterolemia increases vasospasm resulting from basilar artery subarachnoid hemorrhage in rabbits which is attenuated by Vitamin E Surg Neurol Int [online] :29 [viewed 22 October 2014] Available from: doi:10.4103/2152-7806.77600
  26. DEVARA KV, JOSEPH S, UPPU SC. Spontaneous Subarachnoid Haemorrhage Due to Coarctation of Aorta and Intraspinal Collaterals: A Rare Presentation Images Paediatr Cardiol [online] 2012, 14(4):1-3 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663148
  27. PARK CB, JO DJ, KIM MK, KIM SH. Paraplegia due to Acute Aortic Coarctation and Occlusion J Korean Neurosurg Soc [online] 2014 Mar, 55(3):156-159 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2014.55.3.156
  28. BELL BA, SYMON L. Smoking and subarachnoid haemorrhage. Br Med J [online] 1979 Mar 3, 1(6163):577-578 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1598354
  29. DHAR R, DIRINGER M. Statins and Anti-Inflammatory Therapies for Subarachnoid Hemorrhage Curr Treat Options Neurol [online] 2012 Apr, 14(2):164-174 [viewed 22 October 2014] Available from: doi:10.1007/s11940-012-0163-z
  30. OJI Y, NODA K, TOKUGAWA J, YAMASHIRO K, HATTORI N, OKUMA Y. Spontaneous spinal subarachnoid hemorrhage after severe coughing: a case report J Med Case Rep [online] :274 [viewed 22 October 2014] Available from: doi:10.1186/1752-1947-7-274
  31. KUMAR S, GODDEAU RP JR, SELIM MH, THOMAS A, SCHLAUG G, ALHAZZANI A, SEARLS DE, CAPLAN LR. Atraumatic convexal subarachnoid hemorrhage: Clinical presentation, imaging patterns, and etiologies Neurology [online] 2010 Mar 16, 74(11):893-899 [viewed 22 October 2014] Available from: doi:10.1212/WNL.0b013e3181d55efa
  32. KEEDY A. An overview of intracranial aneurysms Mcgill J Med [online] 2006 Jul, 9(2):141-146 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323531
  33. BELLOSO WH, ROMANO M, GRECO GS, DAVEY RT, PERELSZTEIN AG, SáNCHEZ ML, AJZENSZLOS MR, OTEGUI IM. Recurrent Meningitis and Subarachnoid Hemorrhage Due to Salmonella in an HIV+ Patient: Case Report and Mini-Review of the Literature Open AIDS J [online] :62-66 [viewed 22 October 2014] Available from: doi:10.2174/1874613601105010062
  34. GILDEN D, COHRS RJ, MAHALINGAM R, NAGEL MA. Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment Lancet Neurol [online] 2009 Aug, 8(8):731 [viewed 22 October 2014] Available from: doi:10.1016/S1474-4422(09)70134-6
  35. GREEBE P, BROMBERG JE, RINKEL GJ, ALGRA A, VAN GIJN J. Family history of subarachnoid haemorrhage: supplemental value of scrutinizing all relatives. J Neurol Neurosurg Psychiatry [online] 1997 Mar, 62(3):273-275 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1064158
  36. DOSHI R, NEIL-DWYER G. Hypothalamic and myocardial lesions after subarachnoid haemorrhage J Neurol Neurosurg Psychiatry [online] 1977 Aug, 40(8):821-826 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC492843
  37. CHEN S, LI Q, WU H, KRAFFT PR, WANG Z, ZHANG JH. The Harmful Effects of Subarachnoid Hemorrhage on Extracerebral Organs Biomed Res Int [online] 2014:858496 [viewed 22 October 2014] Available from: doi:10.1155/2014/858496
  38. DAI Q, SU L. Neurogenic pulmonary edema caused by spontaneous cerebellar hemorrhage: A fatal case report Surg Neurol Int [online] :103 [viewed 22 October 2014] Available from: doi:10.4103/2152-7806.135579
  39. CASTORI M. Ehlers-Danlos Syndrome, Hypermobility Type: An Underdiagnosed Hereditary Connective Tissue Disorder with Mucocutaneous, Articular, and Systemic Manifestations ISRN Dermatol [online] :751768 [viewed 22 October 2014] Available from: doi:10.5402/2012/751768
  40. VILJOEN DL. Klippel-Trenaunay-Weber syndrome (angio-osteohypertrophy syndrome). J Med Genet [online] 1988 Apr, 25(4):250-252 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1015507

Examination

Fact Explanation
General examination In general examination should look for anaemia, level of hydration, presence of drowsiness, confusion or coma[1][2]
neck stiffness and positive kernig's sign These signs will be positive with meningeal irritation[3][4].
visual impairment There will be double vision, defect in papillary reflex following 3rd cranial nerve palsy. Fundoscopic examination will reveals vitrious haemorrhage, papilloedema[5][6].
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[7][8].
Evidence of recent trauma to head Can look for any wounds, bruises over the head[9][10].
Evidence of increased bleeding tendency multiple bruising patches, patechiae, mucosal bleeding (gum bleeding, epistaxis, haematuria, pv bleeding)[11][12].
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[13][14]. Abdominal examination for presence of abdominal aortic aneurysm (pulsatile abdominal lump) will be useful as aneurysms can occur in all types of vessels[15][16].
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)[17][18][19].
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[20]. Ehlers-Danlos syndrome- mitral valve prolapse, hyperelastic skin, gastrointestinal bleeding, loose hypermobile joints[21]. Klippel-Trenaunay-Weber syndrome- port wine stain, varicose veins, limb hypertrophy[22].
features suggestive of Systemic lupus erythematosus Skin rash, photosensitivity, serositis, joint involvement and features suggestive of multi organ involvement[23][24].
References
  1. PERRY JJ, STIELL IG, SIVILOTTI ML, BULLARD MJ, LEE JS, EISENHAUER M, SYMINGTON C, MORTENSEN M, SUTHERLAND J, LESIUK H, WELLS GA. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study BMJ [online] 2010:c5204 [viewed 22 October 2014] Available from: doi:10.1136/bmj.c5204
  2. AL-SHAHI R, WHITE PM, DAVENPORT RJ, LINDSAY KW. Subarachnoid haemorrhage BMJ [online] 2006 Jul 29, 333(7561):235-240 [viewed 22 October 2014] Available from: doi:10.1136/bmj.333.7561.235
  3. BELLOSO WH, ROMANO M, GRECO GS, DAVEY RT, PERELSZTEIN AG, SáNCHEZ ML, AJZENSZLOS MR, OTEGUI IM. Recurrent Meningitis and Subarachnoid Hemorrhage Due to Salmonella in an HIV+ Patient: Case Report and Mini-Review of the Literature Open AIDS J [online] :62-66 [viewed 22 October 2014] Available from: doi:10.2174/1874613601105010062
  4. DUNCOMBE AS, KENNEDY PG. Spinal subarachnoid haemorrhage presenting as spinal block without meningism. Postgrad Med J [online] 1985 Nov, 61(721):991-993 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2418485
  5. PARK JH, PARK SK, KIM TH, SHIN JJ, SHIN HS, HWANG YS. Anterior Communicating Artery Aneurysm Related to Visual Symptoms J Korean Neurosurg Soc [online] 2009 Sep, 46(3):232-238 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2009.46.3.232
  6. CEBULLA CM, MINNING C, PRATT C, LUBOW M. Charles Bonnet syndrome and Terson's syndrome from subarachnoid hemorrhage: good news from bad news Graefes Arch Clin Exp Ophthalmol [online] 2013 Mar, 251(3):1021-1022 [viewed 22 October 2014] Available from: doi:10.1007/s00417-012-2040-6
  7. KUNDRA S, MAHENDRU V, GUPTA V, CHOUDHARY AK. Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage J Anaesthesiol Clin Pharmacol [online] 2014, 30(3):328-337 [viewed 22 October 2014] Available from: doi:10.4103/0970-9185.137261
  8. ROOS Y, DE HAAN RJ, BEENEN L, GROEN R, ALBRECHT K, VERMEULEN M. Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in The Netherlands J Neurol Neurosurg Psychiatry [online] 2000 Mar, 68(3):337-341 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.68.3.337
  9. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 22 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  10. ARMIN SS, COLOHAN AR, ZHANG JH. Vasospasm in traumatic brain injury Acta Neurochir Suppl [online] 2008 Aug 1, 104(13):421-425 [viewed 22 October 2014] Available from: doi:10.1007/978-3-211-75718-5
  11. ALEXANDER M, PATIL AK, MATHEW V, SIVADASAN A, CHACKO G, MANI SE. Recurrent craniospinal subarachnoid hemorrhage in cerebral amyloid angiopathy Ann Indian Acad Neurol [online] 2013, 16(1):97-99 [viewed 22 October 2014] Available from: doi:10.4103/0972-2327.107712
  12. KIM JS, LEE SH. Spontaneous Spinal Subarachnoid Hemorrhage with Spontaneous Resolution J Korean Neurosurg Soc [online] 2009 Apr, 45(4):253-255 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2009.45.4.253
  13. KULKARNI RR, ADDAGADDE PV. Organic Depression and Terson's Syndrome in Adult Polycystic Kidney Disease: Case Report and Review of Literature Indian J Psychol Med [online] 2014, 36(1):94-97 [viewed 22 October 2014] Available from: doi:10.4103/0253-7176.127267
  14. SCHON F, MARSHALL J. Subarachnoid haemorrhage in identical twins. J Neurol Neurosurg Psychiatry [online] 1984 Jan, 47(1):81-83 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1027647
  15. HOWELL MH, ZAQQA M, VILLAREAL RP, STRICKMAN NE, KRAJCER Z. Endovascular Exclusion of Abdominal Aortic Aneurysms: Initial Experience with Stent-Grafts in Cardiology Practice Tex Heart Inst J [online] 2000, 27(2):136-145 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101048
  16. KIM NS, KANG SH, PARK SY. Coexistence of expanding abdominal aortic aneurysm and aggravated intervertebral disc extrusion -a case report- Korean J Anesthesiol [online] 2013 Oct, 65(4):345-348 [viewed 22 October 2014] Available from: doi:10.4097/kjae.2013.65.4.345
  17. PARK CB, JO DJ, KIM MK, KIM SH. Paraplegia due to Acute Aortic Coarctation and Occlusion J Korean Neurosurg Soc [online] 2014 Mar, 55(3):156-159 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2014.55.3.156
  18. DEVARA KV, JOSEPH S, UPPU SC. Spontaneous Subarachnoid Haemorrhage Due to Coarctation of Aorta and Intraspinal Collaterals: A Rare Presentation Images Paediatr Cardiol [online] 2012, 14(4):1-3 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663148
  19. DOSHI R, NEIL-DWYER G. Hypothalamic and myocardial lesions after subarachnoid haemorrhage J Neurol Neurosurg Psychiatry [online] 1977 Aug, 40(8):821-826 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC492843
  20. KEEDY A. An overview of intracranial aneurysms Mcgill J Med [online] 2006 Jul, 9(2):141-146 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323531
  21. CASTORI M. Ehlers-Danlos Syndrome, Hypermobility Type: An Underdiagnosed Hereditary Connective Tissue Disorder with Mucocutaneous, Articular, and Systemic Manifestations ISRN Dermatol [online] :751768 [viewed 22 October 2014] Available from: doi:10.5402/2012/751768
  22. VILJOEN DL. Klippel-Trenaunay-Weber syndrome (angio-osteohypertrophy syndrome). J Med Genet [online] 1988 Apr, 25(4):250-252 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1015507
  23. KUMAR S, GODDEAU RP JR, SELIM MH, THOMAS A, SCHLAUG G, ALHAZZANI A, SEARLS DE, CAPLAN LR. Atraumatic convexal subarachnoid hemorrhage: Clinical presentation, imaging patterns, and etiologies Neurology [online] 2010 Mar 16, 74(11):893-899 [viewed 22 October 2014] Available from: doi:10.1212/WNL.0b013e3181d55efa
  24. OJI Y, NODA K, TOKUGAWA J, YAMASHIRO K, HATTORI N, OKUMA Y. Spontaneous spinal subarachnoid hemorrhage after severe coughing: a case report J Med Case Rep [online] :274 [viewed 22 October 2014] Available from: doi:10.1186/1752-1947-7-274

Differential Diagnoses

Fact Explanation
Meningitis Meningitis could be septic of aseptic. The differentiation of sub arachnoid haemorrhage from meningitis is important for the management. In meningitis the headache will not be that much severe and acute like in sub arachnoid haemorrhage. Usually the patient will be febrile with headache, photo phobia and features of meningism. Fundoscopy may reveal papiloedema or blurred macular margins. Inflammatory markers would be elevated in meningitis. Imaging with CT brain and Cerebro spinal fluid analysis may differentiate two conditions[1][2].
Cerebral abscess Cerebral abscess also causes rapidly evolving severe headache, features of meningism and focal neurological deficit including focal seizures like in sub arachnoid haemorrhage. In cerebral abscess the headache want be that much sudden onset as in sub arachnoid haemorrhage. Patients with cerebral abscess are usually febrile with a history suggestive of an infective source like otitis media or mastoiditis[3][4].
Simple headaches such as 1. Migraine and 2. Cluster headache 1. Though migraine is an simple headache it causes acute severe headache resembling a sub arachnoid haemmorrhage. Patient may give a history of episodic headache more unilateral which may be associated with photo phobia and porno phobia without features of meningeal irritation. Some may give a history of visual aura preceding the headache. In migraine there will not be any neurological weakness and fundoscopy would be normal. The imaging results would be negative in migraine[5][6]. 2. Cluster headache also a non sinister headache but intractable. Patient will have simillar previous episodes as well. The pain would be characteristically unilateral and associated with nasal congestion, excessive tearing and red eye. Compared to the migraine patient with cluster headache will try to go out, open the windows and inhale well oxygenated are. Typical history would suggest the clinical diagnosis and in suspicious instances imaging is needed to exclude sinister pathologies[7][8].
Intra cranial haemorrhage The patients with intra cranial haemorrhage will present with sudden onset hemi paresis, slurred speech or mouth deviation with sudden onset headache and some times low level of consciousness. Clinical differentiation from sub arachnoid haemmorrhage and ischaemic stroke would be difficult though the headache will be less severe than in typical sub arachnoid haemmorhage. In intra cranial haemmorhage features of meningism would not be obvious. Old patients with poorly controlled hypertension who are chronic smokers presenting with above complains would be typical cases which are more suggestive of an intra cranial hypertension. Simply non contrast CT scan differentiate the conditions[9][10].
Cerebral venous thrombosis In here there will be thrombus formation in the intracranial venous sinuses like sagittal venous sinus, lateral sinus, cavernous sinus, sigmoid sinus and inferior petrosal sinus. Clinical features will be headache, vomiting, seizures, papilloedema, focal neurological signs. Magnetic resonance venogram will useful in diagnosis[11][12].
Ischemic Stroke Ischaemic stroke is fairly a silent paralysis. The patient may complain sudden onset hemiparesis, mouth deviation, vision loss or slurred speech which is usually not associated with headache, seizures or loss of consciousness. Typical patients will be older generation with vascular co-morbidity such as hypertension, smoking, diabetes mellitus and hyperlipidaemia. Imaging with non contrast CT or MRI will show the area of ischaemia[13][14].
Other space occupying lesions such as tumors In these instances the clinical symptoms would be more gradual onset rather than sudden severe symptoms in sub arachnoid haemorrhages. In brain tumors the will be recent history of headache with are characterized by early morning worsening, worsening with straining and relief by vomiting. Other features such as altered behavior, late onset seizures and progressive hemiparesis would suggest a space occupying lesion. Imaging with contrast enhanced CT and MRI would demonstrate the lesion[15][16].
References
  1. EL BASHIR H, LAUNDY M, BOOY R. Diagnosis and treatment of bacterial meningitis Arch Dis Child [online] 2003 Jul, 88(7):615-620 [viewed 22 October 2014] Available from: doi:10.1136/adc.88.7.615
  2. ANJAY MA, ANOOP P. Tuberculous meningitis: more evidence for protective effect of BCG Arch Dis Child [online] 2007 Mar, 92(3):277 [viewed 22 October 2014] Available from: doi:10.1136/adc.2006.109363
  3. KING JE, TURNEY F. Brain Abscess: Evolution of the Methods of Treatment Ann Surg [online] 1954 May, 139(5):587-610 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1609570
  4. BELLER AJ, SAHAR A, PRAISS I. Brain abscess: Review of 89 cases over a period of 30 years J Neurol Neurosurg Psychiatry [online] 1973 Oct, 36(5):757-768 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC494454
  5. COTTRELL CK, DREW JB, WALLER SE, HOLROYD KA, BROSE JA, O’DONNELL FJ. Perceptions and Needs of Patients With Migraine: A Focus Group Study J Fam Pract [online] 2002 Feb, 51(2):142-147 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2128719
  6. PARSEKYAN D. Migraine prophylaxis in adult patients West J Med [online] 2000 Nov, 173(5):341-345 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071161
  7. EVERS S, FISCHERA M, MAY A, BERGER K. Prevalence of cluster headache in Germany: results of the epidemiological DMKG study J Neurol Neurosurg Psychiatry [online] 2007 Nov, 78(11):1289 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.2007.124206
  8. RUSSELL MB, ANDERSSON PG, THOMSEN LL. Familial occurrence of cluster headache. J Neurol Neurosurg Psychiatry [online] 1995 Mar, 58(3):341-343 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073373
  9. NAIDECH AM. Intracranial Hemorrhage Am J Respir Crit Care Med [online] 2011 Nov 1, 184(9):998-1006 [viewed 22 October 2014] Available from: doi:10.1164/rccm.201103-0475CI
  10. SAHNI R, WEINBERGER J. Management of intracerebral hemorrhage Vasc Health Risk Manag [online] 2007 Oct, 3(5):701-709 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314
  11. MARTIN PJ, ENEVOLDSON TP. Cerebral venous thrombosis. Postgrad Med J [online] 1996 Feb, 72(844):72-76 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2398365
  12. ALLROGGEN H, ABBOTT R. Cerebral venous sinus thrombosis Postgrad Med J [online] 2000 Jan, 76(891):12-15 [viewed 22 October 2014] Available from: doi:10.1136/pmj.76.891.12
  13. JICKLING GC, XU H, STAMOVA B, ANDER BP, ZHAN X, TIAN Y, LIU D, TURNER RJ, MESIAS M, VERRO P, KHOURY J, JAUCH EC, PANCIOLI A, BRODERICK JP, SHARP FR. Signatures of cardioembolic and large vessel ischemic stroke Ann Neurol [online] 2010 Nov, 68(5):681-692 [viewed 22 October 2014] Available from: doi:10.1002/ana.22187
  14. STANKOWSKI JN, GUPTA R. Therapeutic Targets for Neuroprotection in Acute Ischemic Stroke: Lost in Translation? Antioxid Redox Signal [online] 2011 May 15, 14(10):1841-1851 [viewed 22 October 2014] Available from: doi:10.1089/ars.2010.3292
  15. MESHKINI A, SHAHZADI S, ALIKHAH H, NAGHAVI-BEHZAD M. Role of stereotactic biopsy in histological diagnosis of multiple brain lesions Asian J Neurosurg [online] 2013, 8(2):69-73 [viewed 22 October 2014] Available from: doi:10.4103/1793-5482.116374
  16. GAGE JT, VANCE EA, HILDENBRAND PG, MATTISON T. Brain lesion and AIDS Proc (Bayl Univ Med Cent) [online] 2000 Oct, 13(4):424-429 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312248

Investigations - for 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[1][2].
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 [2][3][4].
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[5][6].
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[7][8].
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[9][10].
Transcranial Doppler ultrasound This will give an idea about the blood flow of cerebral vessels and useful in identifying brain hypoperfusion[11][12].
References
  1. RESNICK SJ, RABINSTEIN AA. Terson's syndrome in subarachnoid haemorrhage J Neurol Neurosurg Psychiatry [online] 2006 Mar, 77(3):287 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.2005.077628
  2. DIRINGER MN. Management of aneurysmal subarachnoid hemorrhage Crit Care Med [online] 2009 Feb, 37(2):432-440 [viewed 22 October 2014] Available from: doi:10.1097/CCM.0b013e318195865a
  3. GORCHYNSKI J, OMAN J, NEWTON T. Interpretation of Traumatic Lumbar Punctures in the Setting of Possible Subarachnoid Hemorrhage: Who Can Be Safely Discharged? Cal J Emerg Med [online] 2007 Feb, 8(1):3-7 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859734
  4. SCHOFIELD M, LORENZ E, HODGSON T, YATES S, GRIFFITHS P. How well do we investigate patients with suspected subarachnoid haemorrhage? The continuing need for cerebrospinal fluid investigations Postgrad Med J [online] 2004 Jan, 80(939):27-30 [viewed 22 October 2014] Available from: doi:10.1136/pmj.2003.005918
  5. YU DW, JUNG YJ, CHOI BY, CHANG CH. Subarachnoid Hemorrhage with Negative Baseline Digital Subtraction Angiography: Is Repeat Digital Subtraction Angiography Necessary? J Cerebrovasc Endovasc Neurosurg [online] 2012 Sep, 14(3):210-215 [viewed 22 October 2014] Available from: doi:10.7461/jcen.2012.14.3.210
  6. JACAMON M, BONNEVILLE F, ROBERT A, FERREIRA J, BONNEVILLE JF. Cerebral 3D-Gadolinium-DSA in a Patient with Renal Insufficiency Presenting a Subarachnoid Haemorrhage Interv Neuroradiol [online] 2002 Jun, 8(2):193-195 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576612
  7. MITCHELL P, WILKINSON I, HOGGARD N, PALEY M, JELLINEK D, POWELL T, ROMANOWSKI C, HODGSON T, GRIFFITHS P. Detection of subarachnoid haemorrhage with magnetic resonance imaging J Neurol Neurosurg Psychiatry [online] 2001 Feb, 70(2):205-211 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.70.2.205
  8. JADHAV V, SUGAWARA T, ZHANG J, JACOBSON P, OBENAUS A. Magnetic Resonance Imaging Detects and Predicts Early Brain Injury after Subarachnoid Hemorrhage in a Canine Experimental Model J Neurotrauma [online] 2008 Sep, 25(9):1099-1106 [viewed 22 October 2014] Available from: doi:10.1089/neu.2008.0518
  9. HARRIES AD. Subarachnoid haemorrhage and the electrocardiogram - a review. Postgrad Med J [online] 1981 May, 57(667):294-296 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424935
  10. CHATTERJEE S. ECG Changes in Subarachnoid Haemorrhage: A Synopsis Neth Heart J [online] 2011 Jan, 19(1):31-34 [viewed 22 October 2014] Available from: doi:10.1007/s12471-010-0049-1
  11. COMPTON JS, REDMOND S, SYMON L. Cerebral blood velocity in subarachnoid haemorrhage: a transcranial Doppler study. J Neurol Neurosurg Psychiatry [online] 1987 Nov, 50(11):1499-1503 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1032564
  12. SARKAR S, GHOSH S, GHOSH SK, COLLIER A. Role of transcranial Doppler ultrasonography in stroke Postgrad Med J [online] 2007 Nov, 83(985):683-689 [viewed 22 October 2014] Available from: doi:10.1136/pgmj.2007.058602

Investigations - Fitness for Management

Fact Explanation
FBC This will be useful in looking for platelet count, haemoglobin level and WBC count when preparing the patient for invasive procedures and surgeries[1][2].
Clotting profile with PT/ INR, APTT These test also useful to assess the clotting status of the patient[3][4].
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[5][6].
ECG These will be helpful in pre-operative fitness assessment specially in elderly poppulation[7][8].
Chest X ray This will give an idea about lung status and this use before surgical procedures to assess the fitness[9][10].
Blood grouping and cross matching This need to be done pre operatively and blood should be preserved[11][12].
References
  1. BHATTACHARYA I, SANDEMAN D, DWECK M, MCKIE S, FRANCIS M. Electrocardiographic abnormalities in a patient with subarachnoid haemorrhage BMJ Case Rep [online] :bcr0820103253 [viewed 22 October 2014] Available from: doi:10.1136/bcr.08.2010.3253
  2. DUNCAN CW. Neuroimaging and other investigations in patients presenting with headache Ann Indian Acad Neurol [online] 2012 Aug, 15(Suppl 1):S23-S32 [viewed 22 October 2014] Available from: doi:10.4103/0972-2327.99995
  3. CHEN HF, WU TQ, JIN LJ, TANG JQ, ZHU JJ, GE YC, LI ZY, SHEN HS, QIN LM, YU ZQ, WANG ZY. Treatment of vitamin K-dependent coagulation factor deficiency and subarachnoid hemorrhage World J Emerg Med [online] 2011, 2(1):73-76 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129736
  4. ROST NS, MASRUR S, PERVEZ MA, VISWANATHAN A, SCHWAMM LH. Unsuspected coagulopathy rarely prevents IV thrombolysis in acute ischemic stroke Neurology [online] 2009 Dec 8, 73(23):1957-1962 [viewed 22 October 2014] Available from: doi:10.1212/WNL.0b013e3181c5b46d
  5. SHARMA R, MEHTA Y, SAPRA H. Severe aortic stenosis and subarachnoid hemorrhage: Anesthetic management of lethal combination J Anaesthesiol Clin Pharmacol [online] 2013, 29(2):255-257 [viewed 22 October 2014] Available from: doi:10.4103/0970-9185.111662
  6. SIVANASER V, MANNINEN P. Preoperative Assessment of Adult Patients for Intracranial Surgery Anesthesiol Res Pract [online] 2010:241307 [viewed 22 October 2014] Available from: doi:10.1155/2010/241307
  7. CHATTERJEE S. ECG Changes in Subarachnoid Haemorrhage: A Synopsis Neth Heart J [online] 2011 Jan, 19(1):31-34 [viewed 22 October 2014] Available from: doi:10.1007/s12471-010-0049-1
  8. COGHLAN LA, HINDMAN BJ, BAYMAN EO, BANKI NM, GELB AW, TODD MM, ZAROFF JG, IHAST INVESTIGATORS. Independent associations between electrocardiographic abnormalities and outcomes in patients with aneurysmal subarachnoid hemorrhage: findings from the Intraoperative Hypothermia Aneurysm Surgery Trial Stroke [online] 2009 Feb, 40(2):412-418 [viewed 22 October 2014] Available from: doi:10.1161/STROKEAHA.108.528778
  9. DURGA P, JONNAVITHULA N, PANIGRAHI MK, MANTHA S. Unilateral neurogenic pulmonary oedema: An unusual cause for post-operative respiratory dysfunction following clipping of ruptured intracranial aneurysm Indian J Anaesth [online] 2012, 56(1):58-61 [viewed 22 October 2014] Available from: doi:10.4103/0019-5049.93346
  10. KOEDA C, TASHIRO A, TAKAHASHI T, NIIYAMA M, SAKAMOTO R, KIMURA T, MORINO Y, TERUI K, TANAKA R, YOSHIOKA K, KIN H, OKABAYASHI H, NAKAMURA M. Possible Usefulness of Gadolinium-Enhanced Brain MRI for Evaluating Risk of Perioperative Hemorrhage: A Case of Infective Endocarditis Case Rep Cardiol [online] 2014:158041 [viewed 22 October 2014] Available from: doi:10.1155/2014/158041
  11. THOMAS D, WEE M, CLYBURN P, WALKER I, BROHI K, COLLINS P, DOUGHTY H, ISAAC J, MAHONEY P, SHEWRY L, ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN AND IRELAND. Blood transfusion and the anaesthetist: management of massive haemorrhage Anaesthesia [online] 2010 Nov, 65(11):1153-1161 [viewed 22 October 2014] Available from: doi:10.1111/j.1365-2044.2010.06538.x
  12. SIVANASER V, MANNINEN P. Preoperative Assessment of Adult Patients for Intracranial Surgery Anesthesiol Res Pract [online] 2010:241307 [viewed 22 October 2014] Available from: doi:10.1155/2010/241307

Investigations - Followup

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[1][2].
CT scanning This is useful in assessing the complications associated with Sub Arachnoid hemorrhage like rebleeding and hydrocephalus[3][4].
Digital substract angiography This will be helpful during pre-operative and post operative follow up[5][6].
MRI This is useful in follow up of unruptured small aneurysm[7][8].
References
  1. DUNCAN CW. Neuroimaging and other investigations in patients presenting with headache Ann Indian Acad Neurol [online] 2012 Aug, 15(Suppl 1):S23-S32 [viewed 22 October 2014] Available from: doi:10.4103/0972-2327.99995
  2. BHATTACHARYA I, SANDEMAN D, DWECK M, MCKIE S, FRANCIS M. Electrocardiographic abnormalities in a patient with subarachnoid haemorrhage BMJ Case Rep [online] :bcr0820103253 [viewed 22 October 2014] Available from: doi:10.1136/bcr.08.2010.3253
  3. DIRINGER MN. Management of aneurysmal subarachnoid hemorrhage Crit Care Med [online] 2009 Feb, 37(2):432-440 [viewed 22 October 2014] Available from: doi:10.1097/CCM.0b013e318195865a
  4. RESNICK SJ, RABINSTEIN AA. Terson's syndrome in subarachnoid haemorrhage J Neurol Neurosurg Psychiatry [online] 2006 Mar, 77(3):287 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.2005.077628
  5. JACAMON M, BONNEVILLE F, ROBERT A, FERREIRA J, BONNEVILLE JF. Cerebral 3D-Gadolinium-DSA in a Patient with Renal Insufficiency Presenting a Subarachnoid Haemorrhage Interv Neuroradiol [online] 2002 Jun, 8(2):193-195 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576612
  6. YU DW, JUNG YJ, CHOI BY, CHANG CH. Subarachnoid Hemorrhage with Negative Baseline Digital Subtraction Angiography: Is Repeat Digital Subtraction Angiography Necessary? J Cerebrovasc Endovasc Neurosurg [online] 2012 Sep, 14(3):210-215 [viewed 22 October 2014] Available from: doi:10.7461/jcen.2012.14.3.210
  7. JADHAV V, SUGAWARA T, ZHANG J, JACOBSON P, OBENAUS A. Magnetic Resonance Imaging Detects and Predicts Early Brain Injury after Subarachnoid Hemorrhage in a Canine Experimental Model J Neurotrauma [online] 2008 Sep, 25(9):1099-1106 [viewed 22 October 2014] Available from: doi:10.1089/neu.2008.0518
  8. MITCHELL P, WILKINSON I, HOGGARD N, PALEY M, JELLINEK D, POWELL T, ROMANOWSKI C, HODGSON T, GRIFFITHS P. Detection of subarachnoid haemorrhage with magnetic resonance imaging J Neurol Neurosurg Psychiatry [online] 2001 Feb, 70(2):205-211 [viewed 22 October 2014] Available from: doi:10.1136/jnnp.70.2.205

Investigations - Screening/Staging

Fact Explanation
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[2][3]
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[4][5]
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[6]
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[1][7][8]
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[8][9]
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[10][11][12][13].
References
  1. AHMADIAN A, MIZZI A, BANASIAK M, DOWNES K, CAMPORESI EM, THOMPSON SULLEBARGER J, VASAN R, MANGAR D, VAN LOVEREN HR, AGAZZI S. Cardiac manifestations of subarachnoid hemorrhage Heart Lung Vessel [online] 2013, 5(3):168-178 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3848675
  2. CULYER V, MCDONOUGH E, LINDSELL CJ, ALWELL K, MOOMAW CJ, KISSELA BM, FLAHERTY ML, KHATRI P, WOO D, FERIOLI S, BRODERICK JP, KLEINDORFER D, ADEOYE O. Antihypertensives Are Administered Selectively in Emergency Department Patients with Subarachnoid Hemorrhage J Stroke Cerebrovasc Dis [online] 2013 Nov, 22(8):10.1016/j.jstrokecerebrovasdis.2012.02.015 [viewed 22 October 2014] Available from: doi:10.1016/j.jstrokecerebrovasdis.2012.02.015
  3. KING MD, LAIRD MD, SANGEETHA SR, YOUSSEF P, SHAKIR B, VENDER JR, ALLEYNE CH JR, DHANDAPANI KM. ELUCIDATING NOVEL MECHANISMS OF BRAIN INJURY FOLLOWING SUBARACHNOID HEMORRHAGE: AN EMERGING ROLE FOR NEUROPROTEOMICS Neurosurg Focus [online] 2010 Jan, 28(1):E10 [viewed 22 October 2014] Available from: doi:10.3171/2009.10.FOCUS09223
  4. KEEDY A. An overview of intracranial aneurysms Mcgill J Med [online] 2006 Jul, 9(2):141-146 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323531
  5. KIRKPATRICK PJ, MCCONNELL RS. Screening for familial intracranial aneurysms : No justification exists for routine screening BMJ [online] 1999 Dec 11, 319(7224):1512-1513 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117243
  6. BARBARAWI M, SMITH SF, JAMOUS MA, HABOUB H, SUHAIR Q, ABDULLAH S. Therapeutic approaches to cerebral vasospasm complicating ruptured aneurysm Neurol Int [online] , 1(1):e13 [viewed 22 October 2014] Available from: doi:10.4081/ni.2009.e13
  7. ROOS Y, BEENEN L, GROEN R, ALBRECHT K, VERMEULEN M. Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery J Neurol Neurosurg Psychiatry [online] 1997 Oct, 63(4):490-493 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2169792
  8. KUNDRA S, MAHENDRU V, GUPTA V, CHOUDHARY AK. Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage J Anaesthesiol Clin Pharmacol [online] 2014, 30(3):328-337 [viewed 22 October 2014] Available from: doi:10.4103/0970-9185.137261
  9. ELEFTHERIOS A, CARVI Y NIEVAS MN. Acute management of poor condition subarachnoid hemorrhage patients Vasc Health Risk Manag [online] 2007 Dec, 3(6):1075-1082 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350130
  10. WILLIAMS IM, HUGHES OD, TOWNSEND E, WINTER RK, LEWIS MH. Prevalence of abdominal aortic aneurysm in a hypertensive population. Ann R Coll Surg Engl [online] 1996 Nov, 78(6):501-504 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502855
  11. BENTZ S, JONES J. Accuracy of emergency department ultrasound scanning in detecting abdominal aortic aneurysm Emerg Med J [online] 2006 Oct, 23(10):803-804 [viewed 22 October 2014] Available from: doi:10.1136/emj.2006.041095
  12. CHAPMAN AB, WEI W. Imaging Approaches to Patients with Polycystic Kidney Disease Semin Nephrol [online] 2011 May, 31(3):237-244 [viewed 22 October 2014] Available from: doi:10.1016/j.semnephrol.2011.05.003
  13. GRANTHAM JJ. Autosomal Dominant Polycystic Kidney Disease Ann Transplant [online] 2009, 14(4):86-90 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843931

Management - General Measures

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.[21][22]
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. [1][2]
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.[3][4]
Relief anxiety Anxiolytics like benzodiazepine can be use to relief anxiety. This will reduce the stress and calm down the patient.[1][5][6][7]
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.[5]
Pain management Opioid analgesics will be useful in pain management. This will reduce the distress of the patient.[8][9]
Stool softeners This is to reduce training, As straining can worsen the bleeding.[10][11]
Control hypertension Adequate antihypertensive agents (eg; beta blockers, calcium channel blockers) need to be given while continuously monitoring the patients blood pressure.[5][9][12]
Treat seizure If the patients develops seizures tratment with anti convulsant medication with phenytoin, phenobarbital will be needed.[5][13][14]
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.[5][13]
Catheretization This will be important in assessing the urine out put with out disturbing the patient, Also it will allow minimal mobilization.[5]
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.[15][16][17]
Osmotic agents (eg, mannitol) and loop diuretics (eg, furosemide) These will be useful in presence of incresed intracranial pressure.[9][13][18][19]
Anti emetics Anti emetics like promethazine will be useful in the presence of recurrent vomiting.[5][20]
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.[23]
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.[24][25] Hypertension should be controlled with adequate anti hypertensives as high systemic blood pressure is associated with aneurysm rupture.[26] Smoking should be stopped. [27]
References
  1. KUNG DK, CHALOUHI N, JABBOUR PM, STARKE RM, DUMONT AS, WINN HR, HOWARD MA III, HASAN DM. Cerebral Blood Flow Dynamics and Head-of-Bed Changes in the Setting of Subarachnoid Hemorrhage Biomed Res Int [online] 2013:640638 [viewed 22 October 2014] Available from: doi:10.1155/2013/640638
  2. KIM H, BRITTON GL, PENG T, HOLLAND CK, MCPHERSON DD, HUANG SL. Nitric oxide-loaded echogenic liposomes for treatment of vasospasm following subarachnoid hemorrhage Int J Nanomedicine [online] :155-165 [viewed 22 October 2014] Available from: doi:10.2147/IJN.S48856
  3. SODHI HB, 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 [online] 2014, 5(2):118-126 [viewed 22 October 2014] Available from: doi:10.4103/0976-3147.131650
  4. CHEN S, LI Q, WU H, KRAFFT PR, WANG Z, ZHANG JH. The Harmful Effects of Subarachnoid Hemorrhage on Extracerebral Organs Biomed Res Int [online] 2014:858496 [viewed 22 October 2014] Available from: doi:10.1155/2014/858496
  5. DIRINGER MN. Management of aneurysmal subarachnoid hemorrhage Crit Care Med [online] 2009 Feb, 37(2):432-440 [viewed 22 October 2014] Available from: doi:10.1097/CCM.0b013e318195865a
  6. HEDLUND M, ZETTERLING M, RONNE-ENGSTROM E, CARLSSON HEDLUND M, ZETTERLING M, RONNE-ENGSTROM E, CARLSSON M, EKSELIUS L. Depression and post-traumatic stress disorder after aneurysmal subarachnoid haemorrhage in relation to lifetime psychiatric morbidity Br J Neurosurg [online] 2011 Dec, 25(6):693-700 [viewed 22 October 2014] Available from: doi:10.3109/02688697.2011.578769
  7. JOO HM, LEE SJ, CHUNG YG, SHIN IY. Effects of Mindfulness Based Stress Reduction Program on Depression, Anxiety and Stress in Patients with Aneurysmal Subarachnoid Hemorrhage J Korean Neurosurg Soc [online] 2010 May, 47(5):345-351 [viewed 22 October 2014] Available from: doi:10.3340/jkns.2010.47.5.345
  8. AL-SHAHI R, WHITE PM, DAVENPORT RJ, LINDSAY KW. Subarachnoid haemorrhage BMJ [online] 2006 Jul 29, 333(7561):235-240 [viewed 22 October 2014] Available from: doi:10.1136/bmj.333.7561.235
  9. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 22 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  10. KUMAR R, DAS KK, SAHU RK, SHARMA P, MEHROTRA A, SRIVASTAVA AK, SAHU RN, JAISWAL AK, BEHARI S. Angio negative spontaneous subarachnoid hemorrhage: Is repeat angiogram required in all cases? Surg Neurol Int [online] :125 [viewed 22 October 2014] Available from: doi:10.4103/2152-7806.138367
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  13. SAHNI R, WEINBERGER J. Management of intracerebral hemorrhage Vasc Health Risk Manag [online] 2007 Oct, 3(5):701-709 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314
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  15. STECKER M, MICHEL K, ANTAKY K, CHERIAN S, KOYFMANN F. Risk Factors for DVT/PE in Patients with Stroke and Intracranial Hemorrhage Open Neurol J [online] :1-6 [viewed 22 October 2014] Available from: doi:10.2174/1874205X01408010001
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  21. LEE K, CHOI HA, EDWARDS N, CHANG T, SLADEN RN. Perioperative critical care management for patients with aneurysmal subarachnoid hemorrhage Korean J Anesthesiol [online] 2014 Aug, 67(2):77-84 [viewed 22 October 2014] Available from: doi:10.4097/kjae.2014.67.2.77
  22. HINSON HE, HANLEY DF, ZIAI WC. Management of Intraventricular Hemorrhage Curr Neurol Neurosci Rep [online] 2010 Mar, 10(2):73-82 [viewed 22 October 2014] Available from: doi:10.1007/s11910-010-0086-6
  23. BRYANT R. Post-traumatic stress disorder vs traumatic brain injury Dialogues Clin Neurosci [online] 2011 Sep, 13(3):251-262 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182010
  24. SAIFUDDIN A, DATHAN JR. Adult polycystic kidney disease and intracranial aneurysms. Br Med J (Clin Res Ed) [online] 1987 Aug 29, 295(6597):526 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1247431
  25. RIVERA M, GONZALO A, GOBERNADO JM, ORTE L, QUEREDA C, ORTUñO J. Stroke in adult polycystic kidney disease. Postgrad Med J [online] 1992 Sep, 68(803):735-738 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399447
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  27. STARKE RM, CHALOUHI N, ALI MS, JABBOUR PM, TJOUMAKARIS SI, GONZALEZ LF, ROSENWASSER RH, KOCH WJ, DUMONT AS. The Role of Oxidative Stress in Cerebral Aneurysm Formation and Rupture Curr Neurovasc Res [online] 2013 Aug, 10(3):247-255 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845363

Management - Specific Treatments

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.[1][2]
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.[3][4][5][6][7]
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.[4][8]
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[9][10][11].
References
  1. PICKARD JD, MURRAY GD, ILLINGWORTH R, SHAW MD, TEASDALE GM, FOY PM, HUMPHREY PR, LANG DA, NELSON R, RICHARDS P. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ [online] 1989 Mar 11, 298(6674):636-642 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1835889
  2. VERMEULEN M, RINKEL GJ. Management of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry [online] 1994 Jun, 57(6):768-770 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1072999
  3. BALAMURUGAN S, AGRAWAL A, KATO Y, SANO H. Intra operative indocyanine green video-angiography in cerebrovascular surgery: An overview with review of literature Asian J Neurosurg [online] 2011, 6(2):88-93 [viewed 22 October 2014] Available from: doi:10.4103/1793-5482.92168
  4. MAURICE-WILLIAMS RS, LAFUENTE J. Intracranial aneurysm surgery and its future J R Soc Med [online] 2003 Nov, 96(11):540-543 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC539625
  5. KEEDY A. An overview of intracranial aneurysms Mcgill J Med [online] 2006 Jul, 9(2):141-146 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323531
  6. ELEFTHERIOS A, CARVI Y NIEVAS MN. Acute management of poor condition subarachnoid hemorrhage patients Vasc Health Risk Manag [online] 2007 Dec, 3(6):1075-1082 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350130
  7. SAHNI R, WEINBERGER J. Management of intracerebral hemorrhage Vasc Health Risk Manag [online] 2007 Oct, 3(5):701-709 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314
  8. HONG Y, WANG YJ, DENG Z, WU Q, ZHANG JM. Stent-Assisted Coiling versus Coiling in Treatment of Intracranial Aneurysm: A Systematic Review and Meta-Analysis PLoS One [online] , 9(1):e82311 [viewed 22 October 2014] Available from: doi:10.1371/journal.pone.0082311
  9. GANGEMI M, CAVALLO LM, DI SOMMA A, MAZZUCCO GM, BONO PS, GHETTI G, ZAMBON G. Hydrocephalus Onset after Microsurgical or Endovascular Treatment for Acute Subarachnoid Hemorrhage. Retrospective Italian Multicenter Study Transl Med UniSa [online] :50-55 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012376
  10. PICKARD JD. Early posthaemorrhagic hydrocephalus. Br Med J (Clin Res Ed) [online] 1984 Sep 8, 289(6445):569-570 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1442900
  11. KOPITNIK TA, SAMSON DS. Management of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry [online] 1993 Sep, 56(9):947-959 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC489728