Clinical and Neuroimaging Studies in Cases of Spontaneous Subarachnoid Haemorrhage

3. CLINICAL AND NEUROIMAGING STUDIES IN CASES OF SPONTANEOUS SUBARACHNOID HAEMORRHAGE

4. INTRODUCTION

5. INTRODUCTION Subarachnoid haemorrhage (SAH), mostly from aneurysms account for about 4.5 – 13% of all strokes.  The incidence of SAH has remained stable over the last 30 years.  The reported incidence of SAH in the US, Finland & Japan is high, while it is low in New Zealand and Middle East. 

6. INTRODUCTION

7. INTRODUCTION Aetiology: Ruptured intracranial aneurysms. (Commonest)  Cerebral AVMs.  CNS vasculitis.  Cerebral artery dissection  Rupture small superficial artery  Rupture of an infundibulum   Coagulation disorders.

8. INTRODUCTION Aetiology: Dural sinus thrombosis &/or AV fistula.  Spinal AVMs  Pretruncal non-aneurysmal SAH   Rarities: - Tumours - Cocaine abuse - Atrial myxoma - Sickle cell disease - Pituitary apoplexy  No cause in 7 – 10%

9. INTRODUCTION Risk factors: Hypertension  Unruptured aneurysms   Smoking Race  Age   Gender   Alcohol consumption ADPCK  Connective tissue disorders

10. INTRODUCTION Clinical presentation Meningismus 64%  Coma 52%  Nausea & vomiting 45%  No localization sign 39%   Global headache 32%  Occipital headache 21%

11. INTRODUCTION Clinical presentation Reflex changes 19%  Motor deficit 17%  Dysphasia 13%  Confusion 12%  Intraocular haemorrhages 12%  Anisocoria 12% 

12. INTRODUCTION Clinical presentation Papilloedema 11%   Homonymous hemianopsia 9% Lateralized headache 8%   Third nerve palsy 7% Sensory disturbance 5% 

13. INTRODUCTION Complications  Ischaemic deficits 27%  Hydrocephalus 12% Brain swelling 12%  Recurrent haemorrhage 11%  Intracranial hematoma 8%   Pneumonia 8%

14. INTRODUCTION Complications Seizures 5%  Gastrointestinal haemorrhage 4%  SIADH 4%   Pulmonary oedema 1%

15. INTRODUCTION Investigations Computed Tomography (CT) Hydrocephalus 20%  The presence of intraventricular blood (13-28%)  Intraparenchymal blood (20-40%)   Subdural blood (1 - 3%)

16. INTRODUCTION Investigations Computed Tomography (CT) The pattern of SAH  Blood in cistern and fissures   With presence of multiple aneurysms it detect which one bled

17. INTRODUCTION Investigations Lumbar puncture (LP): Elevated opening pressure  Xanthochromia  Elevated proteins   RBCs > 100.000 cm 3

18. INTRODUCTION Investigations CT angiography (CTA): Suspicion of an aneurysm on conventional CT  Follow up of previously diagnosed aneurysm not planned for surgery  Follow up of aneurysm anatomy after surgery   Detection of ruptured aneurysms  Screening

19. INTRODUCTION Investigations MRI: A unique method for identifying aneurysm in patient who not reffered till after 5 – 10 days, and brain CT showed no subarachnoid blood.  FLAIR MRI is more sensitive than CT in detection of acute SAH. 

20. INTRODUCTION Investigations MRA: For detecting aneurysm with sensitivity 85% and specificity around 90%.  For vasospasm identification the sensitivity is 92% and specificity 97%. 

21. INTRODUCTION Investigations TCD: Highly specific 100%, but relatively insensitive in detecting vasospasm.  Assess the intraaneurysmal dynamics. 

22. INTRODUCTION Investigations Cerebral angiography: The gold standard for the diagnosis of the intracranial aneurysm.  Negative in 20%. 

23. INTRODUCTION Investigations Cerebral angiography: Complications:  - Hypersensitivity to contrast agent. - TIA - TGA - Death 1/20 – 40.000

24. INTRODUCTION Management General - Nutrition - Nursing - Blood pressure - Fluid and electrolytes - Pain - Prevention of DVT, or pulmonary embolism

25. INTRODUCTION Management Vasospasm Prophylactic treatment:  -CCB (Nimodipine) -Olprinone -Tirilazed -Otherinvestigational drugs (FK 506, TBC 11.251, L-Argininive monoclonal antibodies. Defferoxamine and prostacyclines, AVS, CGU.

26. INTRODUCTION Management Vasospasm Curative treatment:  -Intrathecal sodium nitroprusside -Nitroglycerine -Cyclosporin -Steroids - Hyperdynamic Therapy (Triple H therapy)

27. INTRODUCTION Management Vasospasm Curative treatment:  - Barbituratecoma - Cisternal irrigation - Genetherapy - Angioplasty - Intra-arterial injection of vasodilator - Intra-aorticcounterpulsation

28. INTRODUCTION Management Rebleeding Antifibrinolytic drugs (TEA, EACA)  Early surgical intervention 

29. INTRODUCTION Management Hydrocephalus Conservative  Repeated LP  Vetriculostomy  Shunt 

30. INTRODUCTION Management Systemic complication Hyponatraemia  Cardiac complications   Pulmonary complications

31. INTRODUCTION Management Endovascular & nonsurgical techniques to treat the aneurysm Trapping  Proximal ligation (hunterian ligation)   Thrombosing aneurysm with GDC & Balloon embolization.

32. INTRODUCTION Management Surgical treatment Clipping  Wrapping   Coating

33. AIM OF THE WORK

34. AIM OF THE WORK This work is carried out to evaluate the clinical presentation and various diagnostic procedures of spontaneous subarachnoid haemorrhage.

35. PATIENTS & METHODS

36. PATIENTS & METHODS 50

37. PATIENTS & METHODS SAH

38. PATIENTS & METHODS PATIENTS WERE SUBJECTED TO CT scanning & CTA History taking Neurological examination MRA MRI FLAIR Laboratory investigations Lumbar puncture 4 vessels angiography

39. PATIENTS & METHODS

40. RESULTS

41. Haemorrhagic stroke Ischemic stroke SAH RESULTS Number and percentage of stroke patients admitted to the neurology department in Mansoura Emergency University Hospital in the period of the study

42. Male Female RESULTS Sex distribution

43. 30 - 39 40 - 49 50 - 59 60 - 69 > 70 RESULTS Age distribution in males

44. 30 - 39 40 - 49 50 - 59 60 - 69 > 70 RESULTS Age distribution in females

45. RESULTS Sex distribution in the different grade of the studied patients

46. RESULTS Clinical Grading System according to H & H.

47. RESULTS Mean age in the different grade of the studied patients

48. 12 AM : 6 AM 6 AM : 12 PM 12 PM : 6 PM 6 PM : 12 AM RESULTS percentage of patients according to time of onset of SAH

49. RESULTS Incidence of SAH in the 24 hours SAH

50. RESULTS Frequency of risk factors