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🧠 Subarachnoid Haemorrhage (SAH)

Thunderclap headache recognition, Hunt-Hess grading, aneurysm securing, vasospasm management, nimodipine and GCC neuroscience nursing exam prep.

Neurology Neurosurgery DHA · SCFHS · QCHP

SAH Overview

Subarachnoid haemorrhage (SAH) is bleeding into the subarachnoid space — the area between the arachnoid and pia mater membranes. 85% of spontaneous SAH results from ruptured intracranial aneurysm. Overall mortality is 25–50%; one-third die before reaching hospital.

Classic Presentation

"Worst headache of my life" + sudden onset = SAH until proven otherwise. Thunderclap headache — maximum severity at onset, within seconds. Any delay in diagnosis is potentially fatal.

Sentinel ("Warning") Headache

Up to 40% of SAH patients report a less severe "warning headache" days to weeks before the main bleed — minor leak from aneurysm before full rupture. This is critical to identify — prompt treatment can prevent the catastrophic main bleed. Nurses must ask about any unusual severe headache in preceding weeks.

Causes

CauseFrequency
Ruptured intracranial aneurysm (berry/saccular)85%
Arteriovenous malformation (AVM)5–10%
Perimesencephalic (non-aneurysmal)5–10%
Other (trauma, CVST, coagulopathy, cocaine)<5%

Grading Scales

Hunt and Hess Grade

GradeClinical FeaturesPrognosis
IAsymptomatic or mild headache, slight nuchal rigidityExcellent (70% good outcome)
IIModerate-severe headache, nuchal rigidity, no neurological deficit except CN palsyGood (60%)
IIIDrowsiness, confusion, mild focal deficitModerate (50%)
IVStupor, moderate-severe hemiparesis, early decerebrate posturingPoor (20%)
VDeep coma, decerebrate posturing, moribund appearanceVery poor (10%)

Fisher Grade (CT Classification)

GradeCT FindingVasospasm Risk
1No SAH on CTLow
2Diffuse thin SAH (<1 mm)Low
3Localised clot or thick SAH (>1 mm)High
4Intraventricular or intracerebral extensionHigh

Fisher grade 3 carries the highest vasospasm risk — critical nursing assessment window is days 4–14 after bleed.

Acute Management

Immediate Priorities

  1. CT head (non-contrast): Hyperdense blood in basal cisterns — sensitivity 98% within 12 hours. After 12 hours sensitivity falls — LP needed if CT negative and clinical suspicion high
  2. Lumbar puncture: If CT negative but clinical suspicion high — perform ≥12 hours after headache onset. Xanthochromia (yellow CSF) confirms SAH from bilirubin breakdown of haemoglobin
  3. CT angiography: Identifies aneurysm location and morphology; guides neurosurgical/neurointerventional planning
  4. Secure aneurysm: Endovascular coiling (preferred) or surgical clipping within 24–72 hours — prevents rebleeding (peak rebleed risk is first 24 hours: 15–20%)
  5. Nimodipine: 60 mg orally (or via NGT) every 4 hours × 21 days — reduces cerebral vasospasm complications

Nursing Monitoring — Neurological ICU

ParameterFrequencyAlert Threshold
GCSEvery 30–60 min acutely; hourly on wardDrop of 2+ points → immediate escalation
PupilsEvery hourUnilateral dilation → CN3 palsy → rebleed / herniation
BPContinuous arterial line; NIBP every 15 minSBP <90 (vasospasm risk) or >160 (rebleed risk) — notify
TemperatureEvery 4 hrsFever >37.5°C worsens cerebral injury — treat aggressively with paracetamol
SodiumDailyHyponatraemia common (cerebral salt wasting or SIADH) — monitor and treat
12-lead ECGOn admission and dailySAH causes neurogenic ECG changes: deep T-wave inversions, QTc prolongation, ST changes; NOT always cardiac in origin

Rebleeding Prevention

Cerebral Vasospasm

Vasospasm window: Days 4–14 post-bleed (peak Day 7). Occurs in 70% of SAH patients; clinical vasospasm (causing ischaemia) in 30%. Leading cause of morbidity and mortality in SAH survivors.

Recognising Vasospasm

Nimodipine — Standard of Care

Nimodipine 60 mg every 4 hours orally × 21 days is the only proven treatment to reduce vasospasm-related complications. It is a calcium channel blocker that reduces smooth muscle contraction in cerebral arteries.

Triple-H Therapy (Historical — Modified Approach)

Classic approach: Hypertension + Haemodilution + Hypervolaemia (Triple-H). Modern evidence supports euvolaemia + induced hypertension only (haemodilution shown to reduce O₂ delivery).

GCC-Specific Context

SAH in GCC

Exam Tips

Exam MCQs — DHA / SCFHS / QCHP

Q1. A 48-year-old patient presents with sudden onset "worst headache of my life" that began while straining at the gym. CT head is reported as "normal." What is the NEXT step?
C — CT sensitivity for SAH falls from 98% at 12 hours to ~85% at 24 hours and continues declining. A negative CT does NOT exclude SAH. Lumbar puncture (LP) at ≥12 hours post-onset: xanthochromia (yellow CSF from bilirubin) confirms SAH. LP before 12 hours may show false-negative from red cell lysis not yet producing bilirubin.
Q2. A SAH patient is 6 days post-bleed. The nurse notes the patient has new left arm weakness that was not present yesterday. What is the MOST LIKELY cause?
B — Day 6 is within the peak vasospasm window (Days 4–14). New focal neurological deficits after initial improvement = cerebral vasospasm until proven otherwise. Urgent TCD/CT perfusion needed. Start/optimise induced hypertension. Nimodipine must be continued. Rebleeding typically causes sudden deterioration with loss of consciousness, not gradual focal deficit.
Q3. A nurse is administering nimodipine 60 mg via nasogastric tube to a SAH patient. The patient's BP drops to 82/54 mmHg. What is the CORRECT action?
B — Nimodipine causes dose-dependent hypotension. SBP <90 mmHg in SAH is dangerous — reduces cerebral perfusion pressure and can precipitate or worsen vasospasm ischaemia. Hold dose, notify team, fluid bolus and vasopressors if needed. Resume nimodipine at reduced dose when BP stable. Do NOT skip doses routinely — the benefit outweighs risk with close monitoring.
Q4. A SAH patient develops serum Na⁺ 125 mmol/L with high urine sodium (45 mmol/L) and signs of dehydration. What is the MOST LIKELY diagnosis and treatment?
B — Cerebral salt wasting (CSW) in SAH: high urinary sodium + hypovolaemia (dehydration). Distinguished from SIADH by volume status — CSW is HYPOvolaemic, SIADH is EUvolaemic. Fluid restriction in CSW worsens hypovolaemia, reduces cerebral blood flow and WORSENS vasospasm risk. Treat with IV fluids (0.9% NaCl) ± fludrocortisone (reduces renal sodium loss).