Podcast #132: Subarachnoid Hemorrhage

86e74b54-4f63-41cb-9119-a546d009c9a2Run Time: 7 minutes

Author: Peter Bakes M.D.

Educational Pearls:

  • Subtypes of stroke are ischemic and hemorrhagic – 87% are ischemic and 13% are hemorrhagic, and half of hemorrhagic strokes are subarachnoid hemorrhage (SAH).
  • SAH are equivalent in morbidity and mortality to ischemic strokes, but they effect younger patients overall.
  • The most common presentation and chief complaint is a sudden severe headache. Patients may also present with unilateral focal neuro deficit, altered mental status or pulseless arrest.
  • Head CT are basically 100% sensitive within first 6 hrs, afterwards an LP may be performed to looks for blood or xanthochromia. Aneurysms at risk for rupture are 7 mm and greater in size. CT angiography (CTA) is sensitive for aneurysms 3mm or larger in size, so many small aneurysms not at high risk of rupture may be detected with CTA. Many will be incidental findings.
  • Complications of SAH include seizures, vasospasm causing ischemia, obstructive hydrocephalus, brain herniation, and re-bleeding.
  • There is a 20% incidence of re-bleeding within the first 2 weeks, with 1-2% bleeding per day, increases risk of subsequent vasospasm.
  • SAH treatment in the ED includes blood pressure control (goal SBP < 140). Currently, short acting titratable IV vasodilators such as nicardipine are preferred. Oral nimodipine may be used as an adjunct to prevent cerebral vasospasm.
  • Patient presentation is predictive of outcome. Awake, alert patients have a good prognosis, while altered or comatose patients have a very poor prognosis.

Link to Podcast: http://medicalminute.madewithopinion.com/subarachnoid-hemorrhage/

References: http://stroke.ahajournals.org/content/43/6/1711.full

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