eMedicine Specialties > Emergency Medicine > Neurology

Subarachnoid Hemorrhage: Follow-up

Author: Rami C Zebian, MD, Resident Physician, Department of Internal Medicine, University of Texas Medical School at Houston
Coauthor(s): A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
Contributor Information and Disclosures

Updated: Feb 25, 2009

Follow-up

Further Inpatient Care

  • Admit to ICU for serial neurologic examinations and for hemodynamic monitoring.
    • Arrange for a darkened, quiet, private room to minimize stimuli that may lead to an elevation of ICP.
    • Closely monitor BP and treat appropriately.
    • Some centers favor volume expansion to treat vasospasm that develops days after the initial bleeding episode.
  • Prevention of rebleeding 
    • The main issue in prevention of rebleeding is treatment of the aneurysm. This is usually done through clipping (surgery) or coiling (endovascular).
    • The choice between coiling and clipping usually depends on the location of the lesion, neck of the aneurysm, as well as availability and experience of hospital staff.
    • Koivisto et al did not show any difference between the two techniques at 1 year; however, the International Subarachnoid Aneurysm Trial (ISAT) showed superiority of coiling at 1 year with extended benefit up to 7 years.10,11
    • For patients in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation, there is firm evidence that, if the aneurysm is considered suitable for both surgical clipping and endovascular treatment, coiling is associated with a better outcome.12
    • Although the timing of surgery has been debated, most neurovascular surgeons recommend early operation. Evidence from clinical trials suggests that patients undergoing early surgery (within 72 h) have a lower rate of rebleeding and tend to fair better than those treated later.13
    • Emergent imaging and intervention may be necessary if mass effect or rebleeding develops.

Transfer

  • Patients with possible ruptured or leaking SAH should be transferred emergently to the closest center with CT scan and neurosurgical staff.
  • Stabilize patients promptly for transfer in an advanced cardiac life support (ACLS)–monitored unit. Address airway and the possible need for intubation or other emergent interventions, such as mannitol and hyperventilation, prior to transfer.

Deterrence/Prevention

  • Screening is generally not recommended in the general population. Even in special population, such as patients with polycystic kidney disease, studies have failed to show any benefit to screening.14
  • In general, screening patients with previous subarachnoid hemorrhage (SAH) cannot be recommended. However, there is a subset of patients with a relatively high risk of both aneurysm formation and rupture. In the latter, screening can save costs and increase quality-adjusted life-years (QALYs). Also, in patients with fear of recurrence, screening may increase QALYs at acceptable costs.15 Nevertheless, more data are needed to (1) identify risk factors for aneurysm formation and rupture in patients with previous subarachnoid hemorrhage and (2) manage fear for a recurrence to identify patients who can benefit from screening.
  • Patients with more than one first-degree relative may benefit from screening with CT or MR angiography.16

Complications

  • Hydrocephalus may develop within the first 24 hours because of obstruction of CSF outflow in the ventricular system by clotted blood.
  • Rebleeding of subarachnoid hemorrhage occurs in 20% of patients in the first 2 weeks. Peak incidence of rebleeding occurs the day after subarachnoid hemorrhage. This may be from lysis of the aneurysmal clot.
  • Vasospasm from arterial smooth muscle contraction is symptomatic in 36% of patients.
  • Neurologic deficits from cerebral ischemia peak at days 4-12.
  • Hypothalamic dysfunction causes excessive sympathetic stimulation, which may lead to myocardial ischemia or labile detrimental BP.
  • Hyponatremia may result from cerebral salt wasting.
  • Aspiration pneumonia and other complications of critical care may occur.
  • Left ventricular systolic dysfunction: LV systolic dysfunction in humans with subarachnoid hemorrhage is associated with normal myocardial perfusion and abnormal sympathetic innervation. These findings may be explained by excessive release of norepinephrine from myocardial sympathetic nerves, which could damage both myocytes and nerve terminals.17

Prognosis

  • Cognitive deficits are present, even in many patients considered to have a good outcome.
  • More than one third of survivors have major neurologic deficits.
  • Factors that affect morbidity and mortality rates are as follows:
    • Severity of hemorrhage
    • Degree of cerebral vasospasm
    • Occurrence of rebleeding
    • Location of bleeding
    • Age and overall health of the patient
    • Presence of comorbid conditions and the hospital course (eg, infections, myocardial infarction)
  • Survival correlates with the grade of subarachnoid hemorrhage upon presentation. Reported figures include a 70% survival rate for grade I, 60% for grade II, 50% for grade III, 40% for grade IV, and 10% for grade V.

Miscellaneous

Medicolegal Pitfalls

  • Failure to detect a sentinel bleed or an actual low-grade SAH
  • Failure to address severe hypertension or hypotension
  • Failure to monitor or stabilize patient with SAH
  • Delay in detecting herniation or a worsening neurologic picture
  • Delay in mobilizing adequate neurosurgical backup
 


More on Subarachnoid Hemorrhage

Overview: Subarachnoid Hemorrhage
Differential Diagnoses & Workup: Subarachnoid Hemorrhage
Treatment & Medication: Subarachnoid Hemorrhage
Follow-up: Subarachnoid Hemorrhage
Multimedia: Subarachnoid Hemorrhage
References
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References

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  2. Schuiling WJ, Dennesen PJ, Tans JT. Troponin I in predicting cardiac or pulmonary complications and outcome in subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. Nov 2005;76(11):1565-9. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Rami C Zebian, MD, Resident Physician, Department of Internal Medicine, University of Texas Medical School at Houston
Rami C Zebian, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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