Elsevier

The Lancet

Volume 369, Issue 9558, 27 January–2 February 2007, Pages 306-318
The Lancet

Seminar
Subarachnoid haemorrhage

https://doi.org/10.1016/S0140-6736(07)60153-6Get rights and content

Summary

Subarachnoid haemorrhage accounts for only 5% of strokes, but occurs at a fairly young age. Sudden headache is the cardinal feature, but patients might not report the mode of onset. CT brain scanning is normal in most patients with sudden headache, but to exclude subarachnoid haemorrhage or other serious disorders, a carefully planned lumbar puncture is also needed. Aneurysms are the cause of subarachnoid haemorrhage in 85% of cases. The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital. Rebleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm. Endovascular obliteration by means of platinum spirals (coiling) is the preferred mode of treatment, but some patients require a direct neurosurgical approach (clipping). Another complication is delayed cerebral ischaemia; the risk is reduced with oral nimodipine and probably by maintaining circulatory volume. Hydrocephalus might cause gradual obtundation in the first few hours or days; it can be treated by lumbar puncture or ventricular drainage, dependent on the site of obstruction.

Section snippets

Epidemiology

The incidence of subarachnoid haemorrhage was overestimated until brain imaging allowed accurate distinction between subarachnoid and intracerebral haemorrhage. In most populations the incidence is 6–7 per 100 000 person-years (after adjustment to age-standardised rates),2, 3 but is around 20 per 100 000 in Finland and Japan.2 Thus, a full-time general practitioner with 2000 patients will see, on average, one patient with subarachnoid haemorrhage about every 7–8 years. Although the incidence

Aneurysms

Intracranial aneurysms are not congenital, as was once believed, but develop in the course of life.7 The best estimate of the frequency of aneurysms for an average adult without specific risk factors is 2·3% (95% CI 1·7–3·1); this proportion increases with age.7 Saccular aneurysms arise at sites of arterial branching, usually at the base of the brain, either on the circle of Willis itself or at a nearby branching point (figure 1). Most intracranial aneurysms will never rupture. The rupture risk

Clinical features

Sudden headache is the most characteristic symptom of subarachnoid haemorrhage; in three out of four patients, the onset is within a split second or a few seconds.27 It is the only symptom in about a third of patients in general practice.32 Conversely, in patients who present with sudden headache alone in general practice, subarachnoid haemorrhage is the cause in one in ten patients.32 Apparently, common headaches with an exceptionally rapid onset outnumber subarachnoid haemorrhage in general

Management

Recommendations for general management and nursing are shown in panel 2. On admission, the first concern is to identify the cause of any reduction in consciousness or focal deficit, before these signs are attributed to the effect of the initial event; some of these causes require immediate intervention. In patients who survive the initial hours after the haemorrhage, three main neurological complications can threaten the patient with a ruptured intracranial aneurysm: rebleeding, delayed brain

Prevention

Three categories need to be considered here. First, there are patients with incidental aneurysms. Second, patients with subarachnoid haemorrhage might have one or more unruptured aneurysms. Last, the question of screening for aneurysms arises in patients who survive an episode of subarachnoid haemorrhage, and in first-degree relatives of patients with subarachnoid haemorrhage.

Search strategy and selection criteria

For literature searches we mainly used our personal database of references. This database has been prospectively built by daily search of PubMed in the past 10–15 years, by means of the following terms “subarachnoid hemorrhage [All Fields] OR subarachnoid haemorrhage [All Fields] OR aneurysm [All Fields] OR arteriovenous malformation [All Fields] OR perimesencephalic [All Fields]”. We also searched the Cochrane library with these terms. We mainly selected studies from the past 10 years,

References (138)

  • AJ Molyneux et al.

    International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion

    Lancet

    (2005)
  • SC Johnston et al.

    The burden, trends, and demographics of mortality from subarachnoid hemorrhage

    Neurology

    (1998)
  • FHH Linn et al.

    Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis

    Stroke

    (1996)
  • C Anderson et al.

    Epidemiology of aneurysmal subarachnoid hemorrhage in Australia and New Zealand: incidence and case fatality from the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS)

    Stroke

    (2000)
  • JW Hop et al.

    Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review

    Stroke

    (1997)
  • B Stegmayr et al.

    Declining mortality from subarachnoid hemorrhage: changes in incidence and case fatality from 1985 through 2000

    Stroke

    (2004)
  • J Huang et al.

    The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis

    Neurosurgery

    (2002)
  • GJE Rinkel et al.

    Prevalence and risk of rupture of intracranial aneurysms: a systematic review

    Stroke

    (1998)
  • VL Feigin et al.

    Risk factors for subarachnoid hemorrhage: an updated systematic review of epidemiological studies

    Stroke

    (2005)
  • YM Ruigrok et al.

    Attributable risk of common and rare determinants of subarachnoid hemorrhage

    Stroke

    (2001)
  • JEC Bromberg et al.

    Subarachnoid haemorrhage in first and second degree relatives of patients with subarachnoid haemorrhage

    BMJ

    (1995)
  • A Ronkainen et al.

    Familial subarachnoid hemorrhage in east Finland, 1977–1990

    Neurosurgery

    (1993)
  • YM Ruigrok et al.

    Characteristics of intracranial aneurysms in patients with familial subarachnoid hemorrhage

    Neurology

    (2004)
  • EW Gieteling et al.

    Characteristics of intracranial aneurysms and subarachnoid haemorrhage in patients with polycystic kidney disease

    J Neurol

    (2003)
  • M Matsuda et al.

    Circumstances precipitating aneurysmal subarachnoid hemorrhage

    Cerebrovasc Dis

    (1993)
  • JR Fann et al.

    Physical activity and subarachnoid haemorrhage: a population based case-control study

    J Neurol Neurosurg Psychiatry

    (2000)
  • C Anderson et al.

    Triggers of subarachnoid hemorrhage: role of physical exertion, smoking, and alcohol in the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS)

    Stroke

    (2003)
  • J van Gijn et al.

    Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage

    Neurology

    (1985)
  • GJE Rinkel et al.

    Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture

    AJNR Am J Neuroradiol

    (1991)
  • TH Schwartz et al.

    Perimesencephalic nonaneurysmal subarachnoid hemorrhage: review of the literature

    Neurosurgery

    (1996)
  • J Zentner et al.

    Subarachnoid hemorrhage of unknown etiology

    Neurol Res

    (1996)
  • WI Schievink et al.

    Pretruncal subarachnoid hemorrhage: an anatomically correct description of the perimesencephalic subarachnoid hemorrhage

    Stroke

    (1997)
  • AN Pinto et al.

    How often is a perimesencephalic subarachnoid haemorrhage CT pattern caused by ruptured aneurysms?

    Acta Neurochir (Wien)

    (1993)
  • YM Ruigrok et al.

    Perimesencephalic hemorrhage and CT angiography: a decision analysis

    Stroke

    (2000)
  • FHH Linn et al.

    Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache

    J Neurol Neurosurg Psychiatry

    (1998)
  • GJE Rinkel et al.

    Acute hydrocephalus in nonaneurysmal perimesencephalic hemorrhage: evidence of CSF block at the tentorial hiatus

    Neurology

    (1992)
  • GJE Rinkel et al.

    Outcome in perimesencephalic (nonaneurysmal) subarachnoid hemorrhage: a follow-up study in 37 patients

    Neurology

    (1990)
  • EH Brilstra et al.

    Quality of life after perimesencephalic haemorrhage

    J Neurol Neurosurg Psychiatry

    (1997)
  • I van der Schaaf et al.

    Venous drainage in perimesencephalic hemorrhage

    Stroke

    (2004)
  • AN Pinto et al.

    Seizures at the onset of subarachnoid haemorrhage

    J Neurol

    (1996)
  • H Butzkueven et al.

    Onset seizures independently predict poor outcome after subarachnoid hemorrhage

    Neurology

    (2000)
  • EH Brilstra et al.

    Rebleeding, secondary ischemia, and timing of operation in patients with subarachnoid hemorrhage

    Neurology

    (2000)
  • JC Reijneveld et al.

    Acute confusional state as presenting feature in aneurysmal subarachnoid hemorrhage: frequency and characteristics

    J Neurol

    (2000)
  • L Caeiro et al.

    Delirium in acute subarachnoid haemorrhage

    Cerebrovasc Dis

    (2005)
  • M Vermeulen et al.

    The diagnosis of subarachnoid haemorrhage

    J Neurol Neurosurg Psychiatry

    (1990)
  • MO McCarron et al.

    A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage

    J Neurol Neurosurg Psychiatry

    (2004)
  • H Stiebel-Kalish et al.

    The natural history of nontraumatic subarachnoid hemorrhage-related intraocular hemorrhages

    Retina

    (2004)
  • G Khechinashvili et al.

    Electrocardiographic changes in patients with acute stroke: a systematic review

    Cerebrovasc Dis

    (2002)
  • LG Toussaint et al.

    Survival of cardiac arrest after aneurysmal subarachnoid hemorrhage

    Neurosurgery

    (2005)
  • N van der Wee et al.

    Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan?

    J Neurol Neurosurg Psychiatry

    (1995)
  • Cited by (1406)

    View all citing articles on Scopus
    View full text