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Traumatic SAH
- 發生率最高, 血在 Brain 表面 Sulcus
Spontaneous SAH
- 75% of atraumatic subarachnoid hemorrhages are caused by a ruptured aneurysm.
- Blood clot @ basal cistern
- 動脈瘤, AVM, 血管炎, 特定藥物濫用 (安非他命, 古柯鹼)
- 動脈瘤大小 < 7mm : low risk
位置後循環破裂風險 > 前循環 > intercavernous 頸動脈瘤
- Within the first 6 hours, CT will reliably identify SAH
A non-contrast head CT has 100% sensitivity within the first 6 hours ;
after this time window, a CT by itself cannot be used to exclude SAH.
Tintinalli : sensitivity 98% within 6 -12 hours of symptom onset
A negative MRI result still needs to be followed by a lumbar puncture.
SAH can be ruled out with 100% sensitivity with implementation of
the Ottawa Subarachnoid Hemorrhage Rule for headache evaluation
may be excluded in patients under 40 years of age, without neck pain or stiffness,
without a witnessed loss of consciousness,
without onset during exertion,
without a thunderclap headache, and without limited neck flexion
Acom aneurysm 破裂有時血塊會偏前方, 甚至 frontal ICH
MCA 則偏外側, 主要在 Sylvian fissure, 偶爾發生 temporal ICH
SAH 因為 CSF 流動會比較快被洗掉
而不像 ICH 這樣腦內的血塊很慢才吸收
所以臨床診斷重要, 病人太晚來急診可能 SAH 就不太明顯了
很多病人的 SAH 過一陣子淡掉, 但是通常還是會有 hydrocephalus
- Unruptured aneurysm : 單側 ptosis, pupil dilated
急性期處置
- 穩定 Vital sign : GCS < 8, IICP, 血流動力學不穩, 可考慮插管
- 持續監控血流動力學以及神經學狀態
- 適當的輸液, 並 follow Na (Hyponatremia)
- 停止使用抗凝血或抗血小板的藥物
- 血壓控制不能太高 (再出血風險), 但太低也可能造成infarction
- 發生SAH後是否需給予抗癲癇藥物預防癲癇
Consideration of seizure prophylaxis is currently supported by several clinical guidelines;
however, this topic remains controversial.
- 嚴重水腦者可考慮放 ventriculostomy 降腦壓, 並監控腦壓狀況
若沒有放置ventriculostomy → 可給予osmotic therapy及利尿劑
動脈瘤治療 可考慮外科手術治療(clipping) 或從血管放 coil
預防 Vasospasm
- Nimodipine, 維持 Euvolemia
- 持續監控病人的神經學症狀，有狀況立刻處理
併發症
Rebleeding, vasospasm, cerebral infarction,
cerebral edema, hydrocephalus, intracranial hypertension,
cerebral edema, hydrocephalus, intracranial hypertension,
fluid status and electrolyte abnormalities, respiratory failure,
myocardial dysfunction, thromboembolism, and sepsis
myocardial dysfunction, thromboembolism, and sepsis
The risk of rebleeding is greatest in the first 2 - 12 hours
SBP 120 to 160 mm Hg
Labetalol and nicardipine are often used, with neither demonstrating clear superiority.
Avoid nitroprusside and nitroglycerin because they increase cerebral blood volume and intracranial pressure
- Vasospasm 血管痙攣
Vasospasm is most common 2 days - 3 weeks after subarachnoid hemorrhage.
Nimodipine, 60 mg PO every 4 hours,
and this therapy should be initiated within 96 hours of symptom onset
and this therapy should be initiated within 96 hours of symptom onset
hemodynamic augmentation：目標要增加腦內的灌流量
提高血壓, 維持足夠的體液
氣球擴張術：如果大血管局部痙攣，直接用氣球撐開
如果是廣泛的血管痙攣→可考慮給予血管舒張劑
- 水腦症 hydrocephalus : 可考慮放引流管減緩症狀
- 低血鈉 : 補充食鹽水
https://thetinynotes.com/topic/287/動脈瘤導致的蛛網膜下腔出血-sah
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