Subarachnoid Hemorrhage

Review and recommendations on management of refractory raised intracranial pressure in aneurysmal subarachnoid hemorrhage

Authors: Mak CH, Lu YY, Wong GK.

Intracranial hypertension is commonly encountered in poor-grade aneurysmal subarachnoid hemorrhage patients. Refractory raised intracranial pressure is associated with poor prognosis. The management of raised intracranial pressure is commonly referenced to experiences in traumatic brain injury. However, pathophysiologically, aneurysmal subarachnoid hemorrhage is different from traumatic brain injury. Currently, there is a paucity of consensus on the management of refractory raised intracranial pressure in spontaneous subarachnoid hemorrhage. We discuss in this paper the role of hyperosmolar agents, hypothermia, barbiturates, and decompressive craniectomy in managing raised intracranial pressure refractory to first-line treatment, in which preliminary data supported the use of hypertonic saline and secondary decompressive craniectomy. Future clinical trials should be carried out to delineate better their roles in management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage patients.

Subarachnoid Hemorrhage and Acute Hydrocephalus as a Complication of C1 Lateral Mass Screws

Authors: George Stovell MM, Pillay MR.

Study Design. Case report.Objective. Present a previously unreported complication of subarachnoid hemorrhage and hydrocephalus after C1 lateral mass screw insertion to inform spine specialists of this potential post-operative complication.Summary of Background Data. Damage to the carotid artery, vertebral artery, hypoglossal nerve and dural tears are all recognized complications. Acute hydrocephalus as a result of subarachnoid hemorrhage is not previously reported.Methods. A 63 year old lady with a traumatic C1 ring and C2 peg fracture underwent C1-C2 fixation. During insertion of the C1 lateral mass screws there was significant hemorrhage from the C1/C2 venous plexus. Three days post-operatively she developed headache, confusion and became drowsy.Results. CT brain revealed hydrocephalus and intraventricular blood that was managed with an external ventricular drain.Conclusion. The case of acute hydrocephalus due to intraventricular hemorrhage from C1 lateral mass screw placement has not previously been reported. Surgeons performing the procedure should consider the diagnosis if patients display signs of raised intracranial pressure post-operatively.

Early brain injury following aneurysmal subarachnoid hemorrhage: emphasis on cellular apoptosis

Authors: Yuksel S, Tosun YB, Cahill J, Solaroglu I.

Subarachnoid hemorrhage (SAH) due to intracranial aneurysm rupture is a complex clinical disease with high mortality and morbidity. Recent studies suggest that early brain injury (EBI) rather than vasospasm might be responsible for morbidity and mortality within 24-72 hours after SAH. The rise in intracranial pressure following SAH causes a significant drop in cerebral perfusion pressure that leads to global cerebral ischemia and initiates the acute injury cascade. Various molecular mechanisms have been shown to involve in the pathophysiology of EBI including cellular apoptosis. In this review, we summarize apoptotic molecular mechanisms involved in the etiology of EBI and its potential as a target for future therapeutic intervention.

Subarachnoid Hemorrhage of Unknown Etiology along the Cortical Convexity

Authors: Murai Y, Kobayashi S, Teramoto A.

Background: Only 8% to 22% of cases of subarachnoid hemorrhage (SAH) are of nonaneurysmal origin. Among these, perimesencephalic nonaneurysmal SAH is a distinct clinical and radiologic entity with normal angiographic findings and a good prognosis. In contrast, SAH of nonaneurysmal origin occurring along the cortical convexity is rare and poorly understood. We report 2 cases of subarachnoid hemorrhage along the cortical convexity and discuss their possible etiologies. Methods: In a retrospective analysis of 234 patients with SAH, we identified 2 patients with a typical computed tomographic pattern of convexity SAH that was associated with no known etiology. Results: In these 2 cases, the source of hemorrhage could not be identified with computed tomography, magnetic resonance imaging, or digital subtraction angiography, although neurovascular outcomes were good. The patients reported such incidents as coughing or exertion immediately before headache developed. These incidents may have caused increased intracranial pressure. Conclusion: We suggest the possible involvement of a brief increase in intracranial pressure, such as that accompanying coughing or exertion, in the occurrence of SAH along the cortical convexity.

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