Subarachnoid hemorrhage natural history, complications and prognosis

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Cerebral Vasospasm and DCI
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Sara Mehrsefat, M.D. [3]

Overview

Natural history

Following rupture of an aneurysm, the blood directly release into the cerebrospinal fluid (CSF) under arterial pressure. As the blood spreads quickly into the CSF, it rapidly increasing intracranial pressure.[1]  Increased intracranial pressure (ICP) occurs secondary to the following factors, including:[2]

Depending on the location of the aneurysm, the blood can spread into:

The bleeding usually lasts only a few seconds. However, rebleeding can be considered as one of the complication which can occur within the first day.[3]

Independent predictors of rebleeding after subarachnoid hemorrhage may include:[4][5][6]

  • The Hunt-Hess grade on admission
  • High bleeding pressure
  • Presence of sentinel headache prior to SAH
  • Early ventriculostomy
  • High blood pressure prior to event

The vasospasm usually occurs following subarachnoid hemorrhage and typically begins no earlier than day three after hemorrhage and peak at days seven to eight. it is thought that the blood clots release a spasmogenic substances following blot clots lysis which can result in vasospasm. The vasospasm can lead to ischemia of the brain which is usually characterized as a single cortical infarcts near the site of the ruptured aneurysm in most case. ischemia of the brain usually results in neurologic deterioration in level of consciousness or new focal neurologic deficits.[7][8]

Risk factors for developing vasospasm may include:[9][10] [11][12]

  • Severe bleeding
  • Bleeding the major intracerebral blood vessels
  • Age less than 50 years
  • Hyperglycemia 

Complications

Complications of SAH can be acute, subacute, or chronic.

Prognosis

Nearly half the cases of SAH are either dead or moribund before they reach a hospital. Of the remainder, a further 10-20% die in the early weeks in hospital from rebleeding. Delay in diagnosis of minor SAH without coma (or mistaking the sudden headache for migraine) contributes to this mortality. Patients who remain comatose or with persistent severe deficits have a poor prognosis.[3]

Following conditions associated with poorer outcome:[15][16][17][18][19][20]

Grading scales

There are several grading scales available for subarachnoid hemorrhage. These have been derived by retrospectively matching characteristics of patients with their outcomes. In addition to the ubiquitously used Glasgow Coma Scale, three other specialized scores are in use.[21][22]

Hunt and Hess scale

The Hunt and Hess scale describes the severity of subarachnoid hemorrhage, and is used as a predictor of survival.[23]

Grading Associations Survival
Grade 1
  • Asymptomatic
  • Minimal headache and slight neck stiffness
  • 70% survival
Grade 2
  • 60% survival
Grade 3
  • Drowsy
  • Minimal neurologic deficit
  • 50% survival
Grade 4
  • 20% survival
Grade 5
  • 10% survival

Fisher Grade

The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan. It is highly predictive of vasospasm[24]

Grading Amount of blood shown on initial CT scans Incidence of symptomatic vasospasm
Grade 1
  • No hemorrhage evident
  • 21%
Grade 2
  • Subarachnoid hemorrhage less than 1 mm thick
  • No clots
  • 25%
Grade 3
  • Subarachnoid hemorrhage more than 1 mm thick
  • localised clots
  • > 30 %
Grade 4
  • Subarachnoid hemorrhage of any thickness with intra-ventricular hemorrhage (IVH) or parenchymal extension or absent blood in basal cisterns
  • > 30 %

World Federation of Neurosurgeons

In assessing outcome of subarachnoid hemorrhage, the World Federation of Neurosurgeons classification recommended use of the Glasgow Coma Scale.[25]

Grading Glasgow Coma Score Motor deficit Interpretation
Grade 1
  • 15
  • Absent
  • Maximum score of 15 has the best prognosis
Grade 2
  • 13-14
  • Absent
  • Scores of 8 or above have a good chance for recovery
Grade 3
  • 13-14
  • Present
  • Scores of 8 or above have a good chance for recovery
Grade 4
  • 7-12
  • Absent/Present
  • Scores of 8 or above have a good chance for recovery
Grade 5
  • 3-6
  • Absent/Present
  • Minimum score of 3 has the worst prognosis
  • Scores of 3-5 are potentially fatal, especially if accompanied by fixed pupils or absent oculovestibular responses

Ogilvy and Carter

Ogilvy and Carter is a combination of clinical and radiological findings. It combined the patient age, Hunt and Hess and Fisher Scales as well as aneurysm size and location to create a new grading system and only surgically treated patients were included in the study.[22]

One point is given for each of the following variables:

  • Age greater than 50
  • Hunt and Hess grade 4 to 5 (in coma)
  • Fisher grade score 3 to 4
  • Aneurysm size >10 mm
  • An additional point is added for a giant posterior circulation aneurysm (≥25 mm)
Grading Outcomes
Grade 1
  • 78% good to excellent outcomes
Grade 2
  • 78% good to excellent outcomes
Grade 3
  • 67% good outcomes
Grade 4
  • 25% good outcomes
Grade 5
  • None with grade 5 had surgery.

References

  1. Schuss P, Konczalla J, Platz J, Vatter H, Seifert V, Güresir E (2013). "Aneurysm-related subarachnoid hemorrhage and acute subdural hematoma: single-center series and systematic review.". J Neurosurg. 118 (5): 984–90. PMID 23289820. doi:10.3171/2012.11.JNS121435. 
  2. Nornes H, Magnaes B (1972). "Intracranial pressure in patients with ruptured saccular aneurysm.". J Neurosurg. 36 (5): 537–47. PMID 5026540. doi:10.3171/jns.1972.36.5.0537. 
  3. 3.0 3.1 Biesbroek JM, van der Sprenkel JW, Algra A, Rinkel GJ (2013). "Prognosis of acute subdural haematoma from intracranial aneurysm rupture.". J Neurol Neurosurg Psychiatry. 84 (3): 254–7. PMID 23117495. doi:10.1136/jnnp-2011-302139. 
  4. Bederson JB, Connolly ES, Batjer HH, Dacey RG, Dion JE, Diringer MN; et al. (2009). "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. 40 (3): 994–1025. PMID 19164800. doi:10.1161/STROKEAHA.108.191395. 
  5. Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K; et al. (2012). "Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage.". Neurology. 78 (1): 31–7. PMC 3466499Freely accessible. PMID 22170890. doi:10.1212/WNL.0b013e31823ed0a4. 
  6. Inagawa T, Kamiya K, Ogasawara H, Yano T (1987). "Rebleeding of ruptured intracranial aneurysms in the acute stage.". Surg Neurol. 28 (2): 93–9. PMID 3603360. 
  7. 7.0 7.1 Haley EC, Kassell NF, Torner JC (1993). "A randomized controlled trial of high-dose intravenous nicardipine in aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study.". J Neurosurg. 78 (4): 537–47. PMID 8450326. doi:10.3171/jns.1993.78.4.0537. 
  8. 8.0 8.1 Weisberg LA (1979). "Computed tomography in aneurysmal subarachnoid hemorrhage.". Neurology. 29 (6): 802–8. PMID 572002. 
  9. 9.0 9.1 Kistler JP, Crowell RM, Davis KR, Heros R, Ojemann RG, Zervas T; et al. (1983). "The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study.". Neurology. 33 (4): 424–36. PMID 6682190. 
  10. Badjatia N, Topcuoglu MA, Buonanno FS, Smith EE, Nogueira RG, Rordorf GA; et al. (2005). "Relationship between hyperglycemia and symptomatic vasospasm after subarachnoid hemorrhage.". Crit Care Med. 33 (7): 1603–9; quiz 1623. PMID 16003069. 
  11. Ko SB, Choi HA, Carpenter AM, Helbok R, Schmidt JM, Badjatia N; et al. (2011). "Quantitative analysis of hemorrhage volume for predicting delayed cerebral ischemia after subarachnoid hemorrhage.". Stroke. 42 (3): 669–74. PMID 21257823. doi:10.1161/STROKEAHA.110.600775. 
  12. Charpentier C, Audibert G, Guillemin F, Civit T, Ducrocq X, Bracard S; et al. (1999). "Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage.". Stroke. 30 (7): 1402–8. PMID 10390314. 
  13. Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K; et al. (2012). "Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage.". Neurology. 78 (1): 31–7. PMC 3466499Freely accessible. PMID 22170890. doi:10.1212/WNL.0b013e31823ed0a4. 
  14. Graff-Radford NR, Torner J, Adams HP, Kassell NF (1989). "Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study.". Arch Neurol. 46 (7): 744–52. PMID 2742543. 
  15. McCarron MO, Alberts MJ, McCarron P (2004). "A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage.". J Neurol Neurosurg Psychiatry. 75 (3): 491–3. PMC 1738971Freely accessible. PMID 14966173. 
  16. Butzkueven H, Evans AH, Pitman A, Leopold C, Jolley DJ, Kaye AH; et al. (2000). "Onset seizures independently predict poor outcome after subarachnoid hemorrhage.". Neurology. 55 (9): 1315–20. PMID 11087774. 
  17. Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K; et al. (2012). "Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage.". Neurology. 78 (1): 31–7. PMC 3466499Freely accessible. PMID 22170890. doi:10.1212/WNL.0b013e31823ed0a4. 
  18. Herrer A (1971). "Leishmania hertigi sp. n., from the tropical porcupine, Coendou rothschildi Thomas.". J Parasitol. 57 (3): 626–9. PMID 5090970. 
  19. Zacharia BE, Ducruet AF, Hickman ZL, Grobelny BT, Fernandez L, Schmidt JM; et al. (2009). "Renal dysfunction as an independent predictor of outcome after aneurysmal subarachnoid hemorrhage: a single-center cohort study.". Stroke. 40 (7): 2375–81. PMID 19461033. doi:10.1161/STROKEAHA.108.545210. 
  20. Wartenberg KE, Mayer SA (2010). "Medical complications after subarachnoid hemorrhage.". Neurosurg Clin N Am. 21 (2): 325–38. PMID 20380973. doi:10.1016/j.nec.2009.10.012. 
  21. Rosen D, Macdonald R (2005). "Subarachnoid hemorrhage grading scales: a systematic review". Neurocrit Care. 2 (2): 110–8. PMID 16159052. 
  22. 22.0 22.1 Rosen, David S., and R. Loch Macdonald. "Subarachnoid hemorrhage grading scales." Neurocritical care 2.2 (2005): 110-118.
  23. Hunt WE, Hess RM (1968). "Surgical risk as related to time of intervention in the repair of intracranial aneurysms.". J Neurosurg. 28 (1): 14–20. PMID 5635959. doi:10.3171/jns.1968.28.1.0014. 
  24. Fisher C, Kistler J, Davis J (1980). "Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning". Neurosurgery. 6 (1): 1–9. PMID 7354892. 
  25. Teasdale G, Drake C, Hunt W, Kassell N, Sano K, Pertuiset B, De Villiers J (1988). "A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies". J Neurol Neurosurg Psychiatry. 51 (11): 1457. PMID 3236024. 

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