SUBARACHNOID HEMORRHAGE

“Worst headache of my life”

Subarachnoid Hemorrhages occur when a blood vessel in the subarachnoid space pops. Usually due to a ruptured aneurysm on the Circle of Willis, which is found in the subarachnoid layer. 

What’s the unique clinical presentation?

SAHs are common, deadly and have a unique clinical presentation. The patient will complain of a thunderclap headache and the worst headache of their life. If the blood compresses their brainstem, then they could lose consciousness. Many patients experience a stiff neck, because the SAH blood contaminates the CSF and that irritates the meninges. 

How to diagnose?

Blood shows up well on CTs. So get a noncontrast CT. Some older doctors may argue that you should do a lumbar puncture. Lumbar punctures are an old school technique (with shoddy predictive values), but the idea is that you look for RBCs or xanthochromia (yellowish color from bilirubin from RBC degeneration) in the CSF. 

How to treat it?

(a) Open up the skull and clip the aneurysm, (b) advance a catheter all the way up to their brain and feed a coil into the aneurysm or (c) triple H therapy (hemodilution, hypertension, hypervolemia). Prevent SAHs with good BP management, smoking cessation and moderate alcohol use. The patient should be hospitalized. After a day or two, many patients will suddenly get worse. It’s due to sudden vasospasms in the brain (we don’t know why this happens). Note that one calcium channel blocker, Nimodipine, has been shown to prevent these vasospasms, and should be given to all patients after being diagnosed with an SAH.