Aneurysmal Subarachnoid Hemorrhage

Abstract

Background: Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living.

Methods: This article is based on a selective review of pertinent literature retrieved by a PubMed search.

Results: Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping).

Conclusion: SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.

Figure 1

Treatment algorithm for aneurysmal SAH from the initial management until the securing of the aneurysm by coiling or clipping. CT, computed tomography; ICP, intracranial pressure; SAH, subarachnoid hemorrhage

Figure 2

Stenting and coiling of a complex aneurysm of the posterior cerebral artery

eFigure 1:

Imaging studies for the detection of subarachnoid hemorrhage and the determination of the source of bleeding. These are the initial imaging studies obtained for a 63-year-old man who was admitted because of the sudden onset of the worst headache of his life, followed by a decline in consciousness. A computed tomogram (CT) of the head displays the classic pattern of a basal subarachnoid hemorrhage, with blood in the basal cisterns appearing as a hyperintense signal in the pentagonal cistern (image a, orange arrow). Subsequent CT angiography and digital subtraction angiography (images b, c) reveal an aneurysm of the anterior communicating artery as the source of bleeding (red arrows). The corresponding 3D reconstructions (images d and e) reveal the spatial configuration of the aneurysm and its spatial relationships to the nearby vessels. A perfusion CT (image f) enables visualization of cerebral perfusion: the parameter displayed here is the regional cerebral blood flow (rCBF)

eFigure 2:

Intraoperative videoangiography with indocyanine green (ICG)