Presented at the Second Neurosurgical MasterClass, Cluj-Napoca, 2014.

1. Subarachnoid Hemorrhage
(SAH)
Ionuţ Cărăvan
Coordinated by Prof. Ioan Ştefan Florian, MD, PhD
University of Medicine and Pharmacy
“Iuliu Haţieganu“ Cluj Napoca

2. Definition
• SAH = extravasation of blood into the subarachnoid
space

3. Etiology
Greenberg Handbook of Neurosurgery, 2010
 Traumatic SAH
 Non-traumatic (spontaneous) SAH
oruptured intracranial aneurysms (75 %)
oAVM (5 %)
oothers (tumor, vasculitis, coagulation disorders, dural
sinus thrombosis)
ounknown etiology (15 %)=“angiogram-negative SAH”

4. Presenting features(1)
• HEADACHE (“thunderclap headache”)
• meningismus
 neck stiffness
 photophobia
 back pain

5. Presenting features(2)
• decreased state of consciousness
• nausea and vomiting
• seizures
• focal neurologic deficits:
 oculomotor palsy
 hemiparesis
• ocular hemorrhage

6. Radiographic findings
• CT scan
• Cerebral Angiography
• FLAIR* MRI
• CT Angiography
• MRA**
*Fluid-attenuated inversion recovery
**Magnetic Resonance Angiography

7. CT scan

8. Lumbar puncture

9. Grading SAH
Hunt and Hess Grade WFNS* Grading
*World Federation of Neurological Surgeons

10. Complications
• Hydrocephalus
• Vasospasm => delayed cerebral ischemia
• Seizures
• Rebleeding
• Intracerebral hemorrhage
• Intraventricular hemorrhage
• Left ventricular systolic dysfunction
• Subdural hematoma

11. Treatment
• BP control (fluid restriction and antihypertensive therapy) when the
mean arterial pressure exceeds 130 mm Hg
• ICP control (osmotic agents, loop diuretics)
• Symptomatic treatment:
– anticonvulsants: levetiracetam, phenytoin
– analgesics: fentanyl
– anti-emetics: odansetron
– calcium channel blockers: nimodipine, verapamil => vasospasm
!!! Prevention of rebleeding:
• antifibrinolytic therapy
• surgical treatment
• endovascular treatment

12. References
• MS Greenberg. Handbook of Neurosurgery. Seventh Edition.
New York: Thieme Medical Publishers; 2010.
• AH Kaye. Essential Neurosurgery. Third Edition. Oxford:
Blackwell Publishing Ltd; 2005.
• MG Yasargil. Microneurosurgery. New York: Thieme Medical
Publishers Inc; 1994.

13. Thank you!