QuestionSBA
QuestionChoice
This is typically used in the treatment of normal pressure hydrocephalus.
10017265
e
Ventriculoperitoneal shunt insertion
QuestionChoice
Decompressive craniectomy is where a bone flap is permanently removed from the skull and is used to treat traumatic brain injuries, chiari malformationss, stroke and other conditions causing a raised ICP. This may become required in the future if cerebral oedema develops, however it is not currently the most appropriate management.
10017264
d
Decompressive craniectomy
QuestionChoice
This is correct. The history and imaging suggests a case of subarachnoid haemmorhage. The immediate priority is to treat vasospasm using nimodipine and optimise blood pressure control (140-160mmHg) to prevent rebleeding.
10017261
a
Nimodipine and blood pressure control
QuestionChoice
Craniotomy is where a bone flap is temporarily removed from the skull and replaced. It is useful in the treatment of space occupying lesions, blood clots, traumatic brain injury (TBI), and can also facilitate implantation of deep brain stimulators for Parkinson's disease.
10017263
c
Craniotomy
QuestionChoice
This is typically used in the treatment of subdural and extradural haematomas, to reduce pressure on the brain.
10017262
b
Burr hole
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This is the final question i will ever see (hopefully) on this platform. My medical finals are on Monday. I hope that other people see this comment and realise that although the road is long, the journey is beautiful. I ponder if the greatest achievement of my life isn't making it through these last 6 years, but realising that the greatest achievement is those we meet along the way. Go well into the night future people who read this. Know that the road you walk was made by the people before you. Go out and do well unto the world. Namastè
43482
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lies i saw you on quesmed yesterday 
43729
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Jargon Dominant
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Migraine Body
Concept
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## Summary

Subarachnoid Haemorrhage (SAH) is a **surgical emergency** that involves bleeding into the subarachnoid space, often due to a ruptured aneurysm. It typically presents with a **sudden, severe "thunderclap" headache** that reaches maximum intensity within 5 minutes and is sometimes described as feeling like "being hit on the back of the head," often with occipital localization. Other symptoms include reduced consciousness, seizures, and localizing neurological signs such as abducens nerve palsy. The initial diagnostic strategy includes a CT head scan followed by a lumbar puncture if indicated. Management includes medical, radiological, and surgical interventions, with **nimodipine** given to prevent vasospasm and **endovascular coiling** as the preferred treatment. SAH carries a significant mortality risk, but prognosis improves with early intervention.

## Definition

A Subarachnoid Haemorrhage (SAH) occurs when blood accumulates in the subarachnoid space, typically due to the rupture of an aneurysm or trauma.

## Epidemiology

- Incidence: SAH occurs in approximately 6-9 per 100,000 people annually. 
- Prevalence: The majority of non-traumatic SAH cases (~80%) are caused by **berry aneurysms**, most commonly on the **posterior communicating artery**.

## Aetiology

SAH can be classified as **traumatic** or **non-traumatic**.

- **Non-traumatic SAH**: 
  - The most common cause is a **ruptured berry aneurysm**. 
  - Other causes include:
  		- Arteriovenous malformations (AVMs)
  		- Arterial dissection
  		- Cerebral amyloid angiopathy.
  - Risk factors include **hypertension (HTN)**, **smoking**, **excessive alcohol consumption**, and **adult polycystic kidney disease (ADPCKD)**, with the latter being a risk factor due to the formation of berry aneurysms.

- **Traumatic SAH**: 
  - Typically caused by head injuries, where blood leaks into the subarachnoid space following trauma.

## Signs and Symptoms

- **Thunderclap headache**: A sudden, severe headache that reaches maximum intensity in less than 5 minutes.
	- Often described as "being hit on the back of the head," commonly with **occipital headache** localization.
- **Seizures**
- **Reduced consciousness** or **loss of consciousness**.
- **Meningism**: Neck stiffness and photophobia.
- Neurological signs: Falsely localizing signs such as **abducens nerve palsy**, due to increased intracranial pressure affecting the longest cranial nerve.
- Vomiting
- Signs of raised intracranial pressure

## Investigations

- **CT head**: The first-line investigation, especially within the first 6 hours of symptom onset, is highly sensitive in detecting SAH. 
- **Lumbar puncture**: Used to assess for xanthochromia, a yellow discoloration in the cerebrospinal fluid indicating the breakdown of red blood cells.
	- Recent NICE guidelines state that if the **CT head is done within 6 hours** of headache onset and shows no SAH, alternative diagnoses should be considered. 
	- If a CT Head is performed more than 6 hours after symptom onset and the result is negative, then a lumbar puncture can be considered at least **12 hours** after symptom onset
- **CT angiography**: To detect any aneurysms or vascular malformations if SAH is confirmed or suspected.

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## Management

Management can be medical, radiological, or surgical:

- **Medical**: 
  - **Nimodipine** is used to prevent delayed cerebral ischemia caused by vasospasm, which can occur after SAH.
  - Blood pressure management: Hypertension is not aggressively treated unless necessary to reduce the risk of rebleeding.

- **Radiological/Surgical**: 
  - **Endovascular coiling** is often preferred over surgical clipping due to better outcomes, but the choice depends on the aneurysm's location and characteristics. 
  - **Clipping** may still be performed, particularly for aneurysms that are unsuitable for coiling.

## Prognosis

- Mortality is around **50%** overall, though many of these deaths occur before patients reach the hospital.
- Among patients with a **Glasgow Coma Scale (GCS)** score of >14 on admission, the survival rate is greater than 90%, with low morbidity.


## References

[NICE Guidance](https://www.nice.org.uk/guidance/ng228)
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A subarachnoid haemorrhage.
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Subarachnoid Haemorrhage
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Haemorrhagic stroke
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Nimodipine is essential in managing subarachnoid haemorrhage to prevent vasospasm and optimise blood pressure control.
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A 65 year old man is brought to the emergency department by ambulance following reports of a severe headache and subsequent loss of consiousness. His GCS is 7. He is intubated and admitted to the ICU.

A CT head shows

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What is the most appropriate next step in the management of this patient?
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