CCRN Subarachnoid Hemorrhage

CCRN Subarachnoid Hemorrhage Overview

Pathophysiology

A subarachnoid hemorrhage is bleeding into the subarachnoid space.  The subarachnoid space is the area between the arachnoid membrane and the pia mater surrounding the brain.  This may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head injury.

SAH is form of stroke and comprises 1 – 7% of all strokes.  It is a medical emergency and can lead to death or severe disability, even when recognized and treated at an early stage.  Up to half of all cases of SAH are fatal and 10 – 15 percent of casualities die before reaching a hospital, and those who survive often have neurological or cognitive impairment.

Signs and Symptoms

• Severe Headache
• Vomiting
• Confusion
• Altered LOC
• Seizures
• Neck stiffness
• Sensitivity to light
• Decreased vision
• Coma

Causes

• Most cases are d/t trauma
• Rupture of cerebral aneurysm
• Use of blood thinners
• Disorders of blood vessels (AV malformations)

Diagnosis

• Medical history
• Physical examination
• CT scan of Head without contrast
• MRI of the brain
• Lumbar puncture
• Cerebral angiography
• ECG changes

Classification

• Grade 1:  Asymptomatic or minimal headache and slight neck stiffness; 70% survival
• Grade 2:  Moderate to severe headache; neck stiffness; no neurologic deficit cranial nerve palsy; 60% survival
• Grade 3:  Drowsy, minimal neurologic deficit; 50% survival
• Grade 4:  Stuporous; moderate to severe hemiparesis; possible early decerebrate rigidity and vegetative disturbances; 20% survival
• Grade 5:  Deep coma; decerebrate rigidity; moribund; 10% survival

Treatment

Management involves general measures to stabilize the patient while also using specific investigations and treatments.  These include the prevention of rebleeding by obliterating the bleeding source, prevention of a phenomenon known as vasospasm, and prevention and treatment of complications.

Stabilizing the patient is first priority.  Those with a depressed LOC may need to be intubated and mechanically ventilated.  Monitor VS and LOC.

Neurosurgeon consult for possible ventricular drain placement.

Prevention of rebleeding and vasospasm