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Management of Subarachnoid Hemorrhage (SAH)

Dr Swapnil Pawar March 12, 2021 667

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    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) 




El-Feky, M., Gaillard, F. (2021). Subarachnoid haemorrhage Radiopaedia. Retrieved February 26, 2021 from


Nickson, C. (2021). Brain Herniation • LITFL • CCC. Retrieved 26 February 2021, from


Tenny S, Thorell W. Intracranial Hemorrhage. [Updated 2020 Jun 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:


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