Chapter 39 Subarachnoid hemorrhage

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Subarachnoid hemorrhage (SAH) is defined as bleeding into the subarachnoid space of the brain. The most common etiology of SAH is trauma, and Other etiologies includes aneurysmal SAH, perimesencephalic hemorrhage, vertebral artery dissection, and arteriovenous malformations (AVMs) to name a few. This chapter focuses on aneurysmal SAH that accounts for approximately 85% of all causes of non-traumatic SAH, and reviews perimesencephalic SAH and SAH from vertebral artery dissection and traumatic SAH. Intracranial aneurysms are uncommon vascular lesions that can cause significant morbidity and mortality if they rupture. Intracranial aneurysms can be defined by their morphology. The majority are saccular in nature although fusiform aneurysms occur. Saccular aneurysms are usually acquired and are believed to result from prolonged hemodynamic stress and subsequent arterial degeneration, particularly at branch points. Hypertension, cigarette smoking, oral contraceptives, alcohol consumption, pregnancy, and cocaine use are all risk factors for aneurysm formation and probably increase the risk of rupture. The four main complications following rupture of an intracranial aneurysm are cerebral vasospasm, aneurismal re-hemorrhage, hydrocephalus, and seizures. The chapter discusses the genetics of intracranial aneurysm formation, diagnostic approach to aneurysmal SAH, pathology of SAH, treatment of ruptured cerebral aneurysms, and other causes of SAH.

Introduction

Subarachnoid hemorrhage (SAH) is defined as bleeding into the subarachnoid space of the brain. The most common etiology of SAH is trauma (Greene 1995, Greene 1996, Taneda 1996, Hanlon 2005). Other etiologies are shown inTable 39.1 and include aneurysmal SAH, perimesencephalic hemorrhage, vertebral artery dissection, and arteriovenous malformations (AVMs) to name a few. Aneurysmal SAH accounts for approximately 85% of all causes of non‐traumatic SAH and will be the focus of this chapter. Perimesencephalic SAH, SAH from vertebral artery dissection and traumatic SAH are briefly reviewed. Isolated spinal SAH is not discussed in this chapter.

Section snippets

Other causes of SAH

Aneurysmal SAH represents 80–85% of all causes of SAH (Rinkel et al., 1993). Perimesencephalic hemorrhage represents 10% and the remaining 5% are caused by various other conditions (Adams 1991, Rinkel 1993) (Table 39.1).

Conclusions

SAH can result from many etiologies. The most frequent overall cause is trauma but aneurysmal SAH accounts for 85% of all non‐traumatic causes. Rapid medical stabilization followed by appropriate investigations and management are important in improving patient outcomes. Diagnostic imaging has improved significantly over the last 15 years but further work is needed. A better understanding and treatment of vasospasm will lead to improved patient outcomes. Finally, patients with SAH are best

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