Subarachnoid hemorrhage

Opinion statement All patients who present with subarachnoid hemorrhage should be admitted to the intensive care unit for close neurologic and cardiorespiratory monitoring. Neurosurgical consultation should be obtained if external ventricular drain placement, arteriography, or surgical planning are considered. Seizure prophylaxis, antihypertensive treatment for mean arterial blood pressure greater than 130 mm Hg, pain control, and bed rest are important measures for the prevention of rebleeding, which is associated with a high mortality rate. Standard deep venous thrombosis and gastrointestinal prophylaxis are recommended to prevent medical complications associated with critical illness. In patients with good-grade subarachnoid hemorrhage, early arteriography and definitive aneurysm management are recommended. The location and neck size of the aneurysm and the medical condition of the patient are factors in the decision to proceed with surgical rather than interventional aneurysm management. Postoperatively, clinical examination and transcranial Doppler ultrasonography are recommended for surveillance of vasospasm. If clinical or arteriographic evidence of vasospasm is present, hemodilution, hypertension, and hypervolemia (triple H) therapy should be instituted. If vasospasm is resistant to conservative measures, balloon angioplasty or intra-arterial papaverine therapy should also be considered.     

Subarachnoid hemorrhage of unknown cause

After the institution of computed tomography (CT), 814 cases of spontaneous subarachnoid hemorrhage (SAH) were treated during a period of 6 years and 9 months (April 1978 through December 1984). In 9 (22.0%) of 41 patients whose cause of SAH was not determined by the first four-vessel study (cerebral panangiography), ruptured aneurysms were found by repeated four-vessel study. Thus, of 814 cases, only 32 (3.9%) were diagnosed as cases of unknown etiology at discharge. The 32 cases were monitored by follow-up examination for 5 to 67 months (median, 27.1 months) after onset. No recurrence of SAH was reported, and all patients were rehabilitated except 2 who suffered terminal carcinoma. A third follow-up four-vessel study was performed 8 to 44 months (median, 22.0 months) after the second study in 14 of the 16 patients with SAH initially demonstrated by CT. In 1 of these cases, an aneurysm found 9 months after the initial SAH was treated surgically. Ultimately, 31 cases (3.8%) were diagnosed as cases of SAH of unknown cause. This incidence is low when compared with those in previous reports. Because of the strict examination schedule including repeated angiography, the incidence is lower and the prognosis is relatively favorable.     

Subarachnoid hemorrhage of unexplained cause

During a 7-year period, we observed 58 patients with signs and symptoms of subarachnoid hemorrhage (SAH) in whom clinical and neuroradiological investigations failed to reveal a reasonable cause of the bleeding. Repeat panangiography was negative in the 2 patients with spasm. Rebleeding episodes soon after admission were rare, and the overall rebleeding rate was 3.4% (equivalent to an annual recurrence of 0.6%). In 1 case, a second extensive angiographic evaluation showed a small cerebral arteriovenous malformation, which was successfully treated surgically. On follow-up, 89% of the patients experienced a good outcome, with return to normal activities. This study confirms a good prognosis for patients with SAH of unknown cause. The necessity of performing a second angiographic study and the role of small infundibular dilations of the cerebral arteries are discussed.     

Subarachnoid hemorrhage in sickle-cell disease

The neurological complications of sickle-cell disease include cerebral intracerebral hemorrhage; subarachnoid hemorrhage (SAH) has been infrequently reported. Among 325 patients with sickle-cell disease followed at the University of Illinois between 1975 and 1989, 11 cases of SAH were identified. Aneurysms were found in 10 of these patients, three of whom had multiple aneurysms. All of the patients had some degree of anemia and nine underwent craniotomy without hematological or neurological complications. From this review it appears that SAH is not uncommon in sickle-cell disease patients and tends to occur at a younger age and with smaller aneurysm size than in the general population. With proper perioperative management, including exchange transfusions to reduce the proportion of hemoglobin S to less than 30%, these patients can undergo angiography and craniotomy without an increased incidence of complications. The techniques used in managing sickle-cell disease patients with SAH are discussed.     

Subarachnoid hemorrhage due to intraspinal tumors

Five cases of subarachnoid hemorrhage arising from an intraspinal tumor are presented, Three of these were ependymomas in the region of the cauda equina. One was a neurofibroma at L1. The fifth was a hemangioblastoma in the upper lumbar region. The literature dealing with subarachnoid hemorrhage due to intraspinal lesions is reviewed. The majority of cases of spinal subarachnoid hemorrhage are due to arteriovenous malformations, but 50 cases in which the bleeding developed from a neoplasm have been reported.     

Subarachnoid hemorrhage after carotid artery stenting

We describe subarachnoid hemorrhage (SAH) in a 66-year-old man, who underwent technically successful carotid stenting for a string-stenosis of the right internal carotid artery (ICA) in a presence of contralateral ICA occlusion with recurrent right hemisphere transient ischemic attacks. At 2 hours, the patient developed headache and vomiting, but no focal neurological deficits. Performed transcranial color-coded Doppler (TCCD) showed over 2.8-fold increase of the peak systolic velocity in the right middle cerebral artery. The emergent CT of the brain showed SAH with the right hemisphere edema. Patient was treated with Nimodipine in continuous infusion, diuretics i.v. and additional hypotensive therapy depending on blood pressure values. Clopidogrel was stopped for 5 days. Over next 4 weeks, a gradual cerebral velocities decrease was observed on TCCD, which was related to clinical and CT resolution.     

Subarachnoid hemorrhage: an update for the intensivist

Subarachnoid hemorrhage (SAH) remains a serious condition with high mortality and disability. In the past decades, there have been improvements in the techniques to secure aneurysms both surgical and endovascular techniques aimed at reducing the risk of future bleeding events. Nevertheless, securing the aneurysm is only the starting point in the care of SAH patients. Intracranial and extracranial complications following SAH are common and impact long-term outcomes. Intensive care management of patients with SAH offers the opportunity to reduce morbidity by reducing secondary insults and preventing complications.     

Subarachnoid hemorrhage due to a spinal neurinoma

A rare observation of spinal neurinoma associated with subarachnoid hemorrhage is reported and the other 12 cases in the literature are reviewed. The extramedullary location of the tumor and the feeble arachnoidal attachments to the spinal cord favor subarachnoidal bleeding in these cases. When the meningeal signs are evident and signs of spinal cord impairment are still unclear, an intracranial origin of the bleeding must be excluded. In doubtful cases, selective spinal angiography is useful in the differential diagnosis between a bleeding spinal tumor and an arteriovenous malformation of the spinal cord.     

Subarachnoid hemorrhage due to retained lumbar drain

Intrathecal spinal catheters (lumbar drains) are indicated for several medical and surgical conditions. In neurosurgical procedures, they are used to reduce intracranial and intrathecal pressures by diverting CSF. They have also been placed for therapeutic access to administer drugs, and more recently, vascular surgeons have used them to improve spinal cord perfusion during the treatment of thoracic aortic aneurysms. Insertion of these lumbar drains is not without attendant complications. One complication is the shearing of the distal end of the catheter with a resultant retained fragment. The authors report the case of a 65-year-old man who presented with a subarachnoid hemorrhage due to the migration of a retained lumbar drain that sheared off during its removal. To the best of the authors' knowledge, this is the first case of rostral migration of a retained intrathecal catheter causing subarachnoid hemorrhage. The authors review the literature on retained intrathecal spinal catheters, and their findings support either early removal of easily accessible catheters or close monitoring with serial imaging.     

Subarachnoid hemorrhage associated with clival chordoma--case report

A 66-year-old man presented with clival chordoma associated with subarachnoid hemorrhage. Computed tomography showed subarachnoid hemorrhage in the right ambient cistern and a well-enhanced tumor in the petroclival region. Surgical exploration performed on the day of admission showed a clot in the tumor. The tumor was totally removed. Histological examination showed hemorrhage between the tumor and the dura. The diagnosis was clival chordoma. Subarachnoid hemorrhage in chordoma seems to occur by spreading of intratumoral hemorrhage into the subarachnoid space due to dural invasion.     

Subarachnoid hemorrhage caused by pilocytic astrocytoma--case report

A 20-year-old woman presented with subarachnoid hemorrhage (SAH) in the frontal interhemispheric fissure, and a cystic lesion in the left frontal lobe. Cerebral angiography demonstrated no aneurysm or vascular abnormalities. T(1)-weighted magnetic resonance imaging with contrast medium revealed an enhanced lesion along the falx. The lesion and cyst were removed, and histological examination revealed a pilocytic astrocytoma. Spontaneous intracranial hemorrhage from pilocytic astrocytoma is rare, with only 15 reported cases mostly involving intratumoral hemorrhage in the parenchyma of hypothalamic and cerebellar tumors. SAH caused by cerebral hemisphere pilocytic astrocytoma is extremely rare. This case suggests that interhemispheric fissure SAH, not associated with aneurysm or abnormal vascularity, could originate from small, low-grade glioma in the superficial cerebral hemisphere.     

Subarachnoid hemorrhage following chymopapain chemonucleolysis. Case report

Subarachnoid hemorrhage is a frequent finding in patients who have incurred neurological complications following chymopapain chemonucleolysis, but the basis for this occurrence remains controversial. The authors report the clinical and postmortem findings in a 42-year-old man who died 5 days after chemonucleolysis at the L4-5 and L5-S1 disc spaces. The predominant histological abnormality was a severe inflammatory arteritis of a medium-sized artery at the upper cervical level with disruption of the vessel wall. The potential causative role of chymopapain in this situation and the correlation of a vascular basis for many of the complications found after inadvertent intrathecal chymopapain injector are discussed.