Management of Subarachnoid Hemorrhage (SAH)

Dr Swapnil Pawar March 12, 2021 155

Management of Subarachnoid Hemorrhage (SAH)
Dr Swapnil Pawar

Subarachnoid Haemorrhage

Written by – Dr Andrew Lam

Types of Intracranial Haemorrhage

Type of Haemorrhage	Location	Affected Vessel	Clinical Presentation	CT Findings
Epidural	Superficial to dura mater	Middle meningeal artery	Usually traumatic in nature with an associated skull fracture. A patient may be initially unconscious from the head strike, recover with a lucid period and then lose consciousness again due to rapid arterial bleed.	Convex (lens-like) hyperdensity
Subdural	Between dura and pia mater	Bridging veins	Usually in older patients with associated brain atrophy. Can present acutely, subacutely or chronically.	Concave hyperdensity
Subarachnoid	Subarachnoid space	Berry aneurysms	Sudden onset (thunderclap) headache, sometimes associated with focal neurological deficits.	Hyperdensity in the sulci and basal cisterns (star sign)
Intracerebral	Brain parenchyma	Small penetrating arteries	Sudden onset stroke-like symptoms with the focal neurological deficit – often in patients with uncontrolled hypertension	Intra-parenchymal hyperdensity

CT Findings of Subarachnoid Haemorrhage

Hyperdensity of the subarachnoid space (sulci, basal cisterns)
Commonly present around the Circle of Willis or Sylvian fissure
“Star Sign”
It May be associated with enlarged ventricles due to hydrocephalus

Types of Herniation

Herniation	Site of Herniation	Symptoms
Uncal Herniation	Herniation of uncus through the tentorial notch	Fixed dilated ipsilateral pupil (CN III Compression) Decreased LOC (Reticular Formation Compression) Hemiplegia (Crus Cerebri Compression)
Subfalcine Herniation	Herniation of cingulate gyrus under the falx cerebri	Behavioural changes and lower limb hemiparesis/sensory loss (Anterior Cerebral Artery Compression)
Tonsillar Herniation	Herniation of cerebellar tonsils through foramen magnum	Autonomic instability, respiratory arrest and ultimately death (Midbrain Compression)

References

El-Feky, M., Gaillard, F. (2021). Subarachnoid haemorrhage Radiopaedia. Retrieved February 26, 2021 from https://radiopaedia.org/articles/subarachnoid-haemorrhage

Nickson, C. (2021). Brain Herniation • LITFL • CCC. Retrieved 26 February 2021, from https://litfl.com/brain-herniation/

Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2020 Jun 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470242/

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