Aneurysmal Subarachnoid Hemorrhage

Abstract

Aneurysmal subarachnoid hemorrhage is a neurologic emergency that requires immediate patient stabilization and prompt diagnosis and treatment. Early measures should focus on principles of advanced cardiovascular life support. The aneurysm should be evaluated and treated in a comprehensive stroke center by a multidisciplinary team capable of endovascular and, operative approaches. Once the aneurysm is secured, the patient is best managed by a dedicated neurocritical care service to prevent and manage complications, including a syndrome of delayed neurologic decline. The goal of such specialized care is to prevent secondary injury, reduce length of stay, and improve outcomes for survivors of the disease.

Keywords: Delayed cerebral ischemia; Intracranial aneurysm; Stroke; Subarachnoid hemorrhage; Vasospasm.

Figure 1:

(A) Axial CT scan in a patient with ruptured anterior communicating aneurysm showing diffuse and thick subarachnoid hemorrhage seen in the basal cisterns (quadrigeminal cisterns, peri-mesencephalic cisterns and in the Sylvian fissures). Minimal intraventricular hemorrhage (white arrow) is also noted layering in the occipital horns of the lateral ventricles which are significantly dilated. (B) Axial CT scan of the same patient showing significant dilatation of the ventricular system consistent with communicating hydrocephalus. A ventricular drain was recently placed with its tip noted in the right lateral ventricle. (C) Follow-up CT scan after endovascular coiling of the ruptured anterior communicating aneurysm with resolution of the subarachnoid blood and significant improvement of the ventricular dilatation. Streak artifacts from the coils is noted. (D) Cerebrospinal fluid (CSF) in a patient with subarachnoid hemorrhage (SAH) showing the red blood cells in the final tube. (E) CSF in a patient without SAH with blood clearing in sequential tubes consistent with a traumatic lumbar puncture.

Figure 2:

Anteroposterior angiogram of the left internal carotid artery in a patient with subarachnoid hemorrhage showing a carotid terminus aneurysm (white arrow) (A). Balloon-assisted coiling of the carotid terminus aneurysm was performed (B) with complete occlusion of the aneurysm (C, black arrow).

Figure 3:

Anteroposterior angiogram of the left internal carotid artery in a patient with aneurysmal subarachnoid hemorrhage at presentation (A) and 8 days later (B) showing interval development of severe vasospasm of the left supra-clinoid carotid artery, left anterior and middle cerebral arteries (white arrows).