Neurology · Year 3 · from Neurology
Case 2: Aneurysmal Subarachnoid Hemorrhage
Patient Demographics
- Age: 48 years old
- Sex: Female
- Occupation: Attorney
Chief Complaint
"Worst headache of my life."
History of Present Illness
Ms. Katherine Ross is a 48-year-old woman who developed sudden onset of severe headache while at work. She describes it as the "worst headache of my life" that came on like a "thunderclap" and reached maximum intensity within seconds. She experienced nausea and vomiting. Coworkers noted she seemed confused. EMS was called and she was transported to the emergency department.
Past Medical History
- Hypertension (inconsistently treated)
- Smoker
Emergency Department
Initial Assessment:
- Vital Signs: BP 178/102, HR 88, Temp 37.2C
- GCS: 14 (E4V4M6) - confused
- Neuro Exam:
- Alert but confused, disoriented to date
- Photophobia
- Nuchal rigidity (meningismus)
- No focal motor deficits
- No pupil abnormalities
Clinical Image
Image: Non-contrast CT head showing diffuse subarachnoid hemorrhage in the basal cisterns and sylvian fissures, appearing as hyperdense (white) blood in the CSF spaces.
Image Source: Wikimedia Commons Attribution: Radiology case, Public Domain URL: https://commons.wikimedia.org/wiki/File:Subarachnoid_hemorrhage_CT.jpg
CT Head (Non-contrast)
Findings:
- Diffuse subarachnoid hemorrhage in basal cisterns, sylvian fissures, and interhemispheric fissure
- Modified Fisher Grade 3 - thick SAH without IVH
- No hydrocephalus
- No parenchymal hematoma
CTA Head
Findings:
- 6mm saccular aneurysm at the anterior communicating artery (AComm) bifurcation
- No other aneurysms identified
- Patent cerebral vasculature, no vasospasm
Hunt and Hess Grading
| Grade | Clinical Features | Patient |
|---|---|---|
| 1 | Asymptomatic or mild headache | No |
| 2 | Moderate-severe headache, nuchal rigidity, no deficit | YES |
| 3 | Drowsiness, confusion, mild focal deficit | No |
| 4 | Stupor, moderate-severe hemiparesis | No |
| 5 | Coma, decerebrate posturing | No |
Patient is Hunt and Hess Grade 2 - relatively good prognosis with treatment
Management Plan
Immediate Priorities:
- Prevent Rebleeding (highest early risk):
- Blood pressure control: Target SBP <160 mmHg until aneurysm secured
- Nicardipine drip started
- Strict bed rest
- Minimize stimulation
- Stool softeners (avoid Valsalva)
- Secure the Aneurysm (within 24 hours):
- Neurosurgical and neurointerventional consultation
- Decision: Endovascular coiling (AComm aneurysm favorable anatomy)
- Performed within 12 hours of admission
- Prevent Vasospasm:
- Nimodipine 60mg PO/NG every 4 hours x 21 days - improves outcomes
- Note: Nimodipine does NOT prevent vasospasm on imaging but improves clinical outcomes
- Maintain Cerebral Perfusion:
- After aneurysm secured: Allow higher BP (no longer need SBP <160)
- Euvolemia - avoid hypovolemia
- Maintain hemoglobin >8 g/dL
- Monitoring:
- Neurological examination every 1-2 hours
- Daily transcranial Doppler (TCD) starting day 3 to monitor for vasospasm
- Repeat imaging if clinical change
Post-Coiling Course
Day 1-3:
- Aneurysm coiled successfully
- Neurologically stable
- No hydrocephalus on repeat CT
Day 5-14 (Vasospasm Window):
- Day 7: TCD shows elevated velocities in bilateral MCAs (150 cm/s)
- Day 8: New confusion, mild left arm weakness
- Clinical vasospasm suspected
Management of Vasospasm:
- Permissive hypertension (SBP 180-200 mmHg)
- Euvolemia confirmed
- Emergent cerebral angiogram: Moderate right MCA vasospasm
- Intra-arterial verapamil and balloon angioplasty performed
- Clinical improvement within hours
Other Complications Monitored:
| Complication | Status |
|---|---|
| Rebleeding | No (aneurysm secured) |
| Vasospasm | Day 7-8 (treated) |
| Hydrocephalus | Mild ventriculomegaly day 10, no EVD needed |
| Hyponatremia | Na 132 day 6, SIADH, fluid restriction |
| Seizures | None |
Day 14:
- Neurologically at baseline
- Transferred to rehabilitation
- Modified Rankin Scale: 1 (no significant disability)
Teaching Points
- "Worst headache of my life" = SAH until proven otherwise
- CT head (95% sensitive if <6 hours)
- LP if CT negative but clinical suspicion high
- Secure the aneurysm within 24 hours to prevent rebleeding (highest risk in first 24 hours)
- Vasospasm is the major delayed complication:
- Occurs days 3-14 (peak days 7-10)
- Monitor with serial neuro exams and TCD
- Treat with induced hypertension and endovascular intervention
- Nimodipine 60mg q4h x 21 days is standard of care - improves outcomes despite not preventing angiographic vasospasm
- Hunt and Hess grade correlates with prognosis:
- Grade 1-2: Good outcomes expected
- Grade 4-5: Poor prognosis
- Hyponatremia is common - usually SIADH; can also be cerebral salt wasting