Clinical Features and Management of Subarachnoid Hemorrhage

Clinical Features of Subarachnoid Hemorrhage and Principles of Diagnosis and Management Subarachnoid hemorrhage (SAH) is a critical neurological emergency characterized by bleeding into the subarachnoid space, typically due to the rupture of an intracranial aneurysm. It accounts for approximately 5% of all strokes but has a high mortality rate if not promptly diagnosed and managed. Understanding its clinical features, diagnostic principles, and management strategies is essential for improving outcomes in affected patients. Clinical Features 1. Sudden Onset Headache: o Often described as the worst headache of one's life (thunderclap headache). o Headache may be abrupt in onset and severe, typically peaking within seconds to minutes. 2. Neurological Symptoms: o Altered level of consciousness ranging from mild confusion to coma. o Focal neurological deficits such as hemiparesis (weakness on one side of the body), visual disturbances, or cranial nerve palsies. 3. Nuchal Rigidity: o Stiff neck due to irritation of the meninges, often associated with meningeal signs (e.g., Kernig's or Brudzinski's signs). 4. Vomiting: o Nausea and vomiting, often occurring early after onset of symptoms. 5. Seizures: o May occur in some patients, especially if the hemorrhage extends into brain tissue. 6. Photophobia: o Sensitivity to light due to meningeal irritation. Principles of Diagnosis 1. Imaging Studies: o Non-Contrast CT Scan: Initial imaging modality of choice to detect acute hemorrhage within the first 6-12 hours. o CT Angiography (CTA): Useful for identifying the presence, location, and size of intracranial aneurysms causing SAH. o Digital Subtraction Angiography (DSA): Gold standard for detecting and characterizing intracranial aneurysms, especially when planning surgical or endovascular intervention. 2. Lumbar Puncture: o Considered if initial CT scan is negative but suspicion for SAH remains high. o Presence of xanthochromia (yellowish discoloration of cerebrospinal fluid) confirms SAH, indicating breakdown of red blood cells in the subarachnoid space. Management Strategies 1. Immediate Stabilization: o Secure airway, breathing, and circulation (ABCs). o Maintain adequate oxygenation and blood pressure to prevent secondary brain injury. 2. Neurosurgical Consultation: o Early involvement of neurosurgical team for consideration of surgical clipping or endovascular coiling of the ruptured aneurysm. 3. Medical Management: o Nimodipine: Calcium channel blocker administered to prevent cerebral vasospasm, which can lead to ischemic complications post-SAH. o Antiepileptic Drugs (AEDs): Prophylactic use to prevent early seizures, especially if the hemorrhage is extensive. 4. Monitoring and Supportive Care: o Continuous monitoring of neurological status, including Glasgow Coma Scale (GCS), pupillary responses, and motor function. o Intensive care unit (ICU) admission for close monitoring of vital signs and ICP if indicated. 5. Complications Management: o Cerebral Vasospasm: Monitor for signs and symptoms and initiate treatment promptly with hypertensive therapy or endovascular interventions if detected. o Hydrocephalus: Address with ventriculostomy or placement of a ventriculoperitoneal shunt if there is evidence of obstructive hydrocephalus. Prognosis and Follow-Up   The prognosis of SAH depends on several factors including the extent of hemorrhage, presence of complications (e.g., vasospasm, hydrocephalus), and promptness of intervention. Long-term follow-up includes rehabilitation to address physical and cognitive deficits, psychological support, and monitoring for recurrence or complications of treatment. Conclusion Subarachnoid hemorrhage presents with characteristic sudden onset severe headache and neurological deficits, requiring urgent evaluation and intervention to prevent morbidity and mortality. Early diagnosis through imaging and lumbar puncture, along with prompt neurosurgical consultation and medical management, are critical for optimizing outcomes. Multidisciplinary care involving neurologists, neurosurgeons, intensivists, and rehabilitation specialists is essential for comprehensive management and long-term recovery of patients with SAH.