Traumatic Vs SpontaneousSubarachnoid Hemorrhage (SAH)

1. Traumatic Vs Spontaneous
Subarachnoid Hemorrhage (SAH)
Dr Amit Agarwal
Professor of Neurosurgery
Narayana Medical College and Hospital
Nellore (AP)

2. • Conflict of interest: None
• Financial support: Nil
Disclosures

3. • Many more conditions
Trauma first or pathology first
Seizures Trauma
Loss of consciousness Trauma
Intracranial hemorrhage Trauma
Focal weakness Trauma

4. • It can be spontaneous
• It can be traumatic
• Spontaneous SAH can lead to trauma
(aneurysmal rupture while driving)
• Rupture of traumatic aneurysms can lead to
SAH
Puzzle of spontaneous versus
traumatic SAH

5. • What is subarachnoid space?
• What is SAH?
• What are the causes of SAH?
• What are the clinical features?
• How to make a diagnosis?
• How to plan the management?
First thing first
"The eye cannot see what the mind does not know”

6. What is subarachnoid space?

7. • Subarachnoid Hemorrhage (SAH) is a
collection of blood into the subarachnoid
space
• Common source is arteries (ruptured
aneurysm or arteial tears) traversing through
the subarachnoid space
What is SAH?

8. • Traumatic SAH (26-53% of all trauma cases)
• Spontaneous SAH
– Spontaneous rupture of an aneurysm (80-85%)
• Many other diseases
– Cerebral amyloid angiopathy
– Arteriovenous malformation
– Septic aneurysm
– Cocaine associated SAH
– Moya-moya disease
– Sickle cell disease
– Pituitary apoplexy
– Vertebral dissection
– Carotid dissection
Causes of SAH

9. Clinical presentation
sSAH tSAH
Headache Sudden severe
headache
Thunderclap headache
Worst headache ever
varying severity
Sentinel headache ✓ ✕
Altered consciousness ✓ ✓
Confusion and irritability ✓ ✓
Nausea and vomiting ✓ ✓
Meningeal irritation ✓ Please do not elicit neck rigidity
Seizures ✓ ✓
Neurological deficits ✓ ✓
Retinal hemorrhages ✓ ✓
Trauma  ✓

10. • Elaborate clinical history
• A complete neurological evaluation
– Level of consciousness
– Pupillary examination
– Reflexes
– Motor response
– Clinical history
– Examination
• Look for signs of injuries including C-spine
• Imaging appearance
• A high index of suspicion
Algorithm to approach

11. Investigations: Non-contrast CT scan
• Initial investigation of choice
– Presence of SAH
– Distribution of blood
– Extent of hemorrhage
– Any associated lesions

12. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 33934
Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 4852

13. • Angiography
– CTA
– DSA
– MRA
• Lumbar puncture (Please rule out any
intracranial mass lesions)
Further investigations

14. Management
sSAH tSAH
Airway ✓ ✓
Breathing ✓ ✓
Circulation ✓ ✓
Disability assessment ✓ ✓
Anti-epileptics ✓ ✓
Supportive management ✓ ✓
Management of raised ICP ✓ ✓
Management of vasospasm ✓ ✓
Euvolemia ✓ ✓
Normothermia ✓ ✓
Treatment of underlying etiology Aneurysm clipping

15. • Even though etiological classification
categorizes traumatic and non-traumatic or
spontaneous (SAH) separately, in many
aspects the clinical presentation and
management significantly overlaps
• However, differentiation between tSAH and
sSAH is important as the definitive treatment
is not same
Conclusions

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References