A Case Study Presentation

on
Subarachnoid
Hemorrhage
Presented by:
Asma Alzahrani
Asma Alshehri
Nada Atallah
Layla Ali Akam
Rawan Almarwani
Shrog Mfleh Alblwi
Jawaher Alharbi
Norah Ahmed
Khlood alatwi
Why we choose this
case ?
General Objectives:
The primary concern of this Case Study Presentation is to
further enhance the understanding of Subarachnoid
Hemorrhage in congruence with the learned concepts of the
Nursing students.
• Specific Objectives:
This case presentation seeks to provide different information about the
disease being considered with the ff. specific objectives:
Give a brief introduction about Subarachnoid Hemorrhage together with
the clinical manifestations.
Present the clients demographic and health history.
Present the abnormal results of the physical assessment and compare it
to the normal.
Present the different laboratory test and results done to the clients with
its interpretation.
5. Discuss the normal Anatomy and Physiology of Central Nervous
System.
6. Explain the Pathophysiology of Subarachnoid Hemorrhage.
7. Discuss the drug study.
8. Present a Nursing Care Plan.
9. Show a Discharge Planning that the client may use upon discharge
to the hospital.
 Outline:
I. Introduction
Statistics ( incidence and prevalence)
II. Patient/Case Presentation
a. Assessment
b. Demographics
c. Lifestyle
d. Family history
e. Medical History:
III. Anatomy and Physiology
IV. Medical Management l Interventions
a. Medications
b. Medical interventions
c. Diagnostic and laboratory tests
V. Nursing Interventions
V. Conclusion & Recommendation
VI. References
 introduction:

A subarachnoid hemorrhage is an uncommon type of

stroke caused by bleeding on the surface of the brain.
It is a very serious condition and can be fatal

SAH : fourth most frequent cerebrovascular disorder-

following athero-thrombosis, embolism and primary
intra-cerebral hemorrhage.

CAUSE: Excluding head trauma, the most common

cause of SAH is rupture of vascular aneurysm.
 Definition:

Subarachnoid Hemorrhage:
Bleeding in the area between the brain and
the thin tissues that cover the brain.
This area is called the subarachnoid space
Incidence and Prevalence
• The doctors have confirmed that the main caused
by the presence stretch in one of the main arteries
feeding the brain, and that in 90% of cases as there
are up to 5% of normal people are predisposed to
occurrence of this expansion, and there are 10
people out of every 100 thousand people each
year enter the stage It is called infiltration bloody
phase, which precedes the bleeding or explosion,
and the best treatment of these cases before
entering into this phase where increasing the
chances of successful surgical treatment to 99% if
caught early.

10-12% die before receiving medical attention.

Many risk factors have been implicated in the pathogenesis of
aneurysmal SAH. They include:
age collagen vascular disease

gender oral contraceptive

use
smoking

alcohol use

arterial hypertension

atherosclerosis

size of unruptured aneurysm

drug abuse

body mass index

analgesic use

race
and other genetic factors:

a. the incidence of aneurysmal SAH increases with age

reaching a peak in the sixth decade of life.
b. sex: in adults, woman are affected more than men by a
ratio of 3 : 2
c. aneurysmal SAH is rare in children and boys are affected
more than girls by a ratio of 3 : 1
d. race: African-Americans are at a higher risk than white
Americans
e. the critical size of aneurysms determining the risk of
rupture is reported to be between 5 and 7 mm .
f. 11% of patients with either a ruptured or unruptured
aneurysm had a family history of cerebrovascular
disease(compared with 4% of matched controls)
 Causes:
Subarachnoid hemorrhage can be caused by:
•Bleeding from (AVM)
•Bleeding disorder
•Bleeding from a
•Head injury
•Unknown cause (idiopathic)
•Use of blood thinners
Subarachnoid hemorrhage caused by injury is often
seen in the elderly who have fallen and hit their head.
Among the young, the most common injury leading to
subarachnoid hemorrhage is motor vehicle crashes.
 Risks Include:
in other blood vessels
An aneurysm is an abnormal widening or ballooning of a
portion of an artery due to weakness in the wall of the
blood vessel
•Fibromuscular dysplasia (FMD) and other connective
tissue disorders
•High blood pressure
•History of
Polycystic kidney disease is a kidney disorder passed
down through families in which many cysts form in the
kidneys, causing them to become enlarged.
•Smoking
•A strong family history of aneurysms may also increase
your risk.
 Internal carotid artery

Posterior
communicating artery

aneurysm
subarachnoid hemorrhage (SAH) is classified
according to 5 grades, as follows
• Grade I: Mild headache with or without meningeal irritation
• Grade II: Severe headache and a nonfocal examination, with or
without mydriasis
• Grade III: Mild alteration in neurologic examination, including mental
status
• Grade IV: Obviously depressed level of consciousness or focal deficit
• Grade V: Patient either posturing or comatose
 Symptoms:
The main symptom is a severe headache that starts
suddenly (often called thunderclap headache). It is
often worse near the back of the head. Many
persons often describe it as the "worst headache ever"
and unlike any other type of headache pain. The
headache may start after a popping or snapping
feeling in the head.
Other symptoms:
and alertness
Eye discomfort in bright
Mood and personality changes, including
and irritability
(especially
Nausea and vomiting
Symptoms continuation…

• Numbness in part of the body

• Stiff neck
 treatment

The goals of treatment are to:

•Save life
•Repair the cause of bleeding
•Relieve symptoms
•Prevent complications such as permanent
brain damage (stroke)
 Prognosis:

• How well a patient with subarachnoid hemorrhage

does depends on a number of different factors,
including:
• Location and amount of bleeding
• Complications
• Older age and more severe symptoms can lead to
a poorer outcome.
• People can recover completely after treatment.
But some people die even with treatment.
Possible Complications
 PATHOPHYSIOLOGY
Modifiable Risk Factors
Non-modifiable Risk Factors> >HPN
Advanced Age >Smoking
>Gender >excessive intake of foods
>Heredity high in fats and
cholesterol

Triggering Factors
>Sudden extreme emotion

Cerebral aneurysm rupture

Arterio venous malformation

Bleeding into the brain tissue and

subarachnoid space
 Blood Clots in the Subarachnoid
Space

Blood supply interruption

Brain Compression

Tissue Necrosis

Increase Intracranial
Neuronal Death Pressure

Regional Paralysis
Epileptic Seizure : increase
T intraocular pressure=
total Paralysis blindness

Coma

Death
Name: S.M
Date of birth: December 14, 1984
Age: 31 years
Gender: Female
Marital status : Married
Admission Date: 25/02/2015
Diagnosis: Subarachnoid hemorrhage
Chief complaint: Headache, hypertension and
projectile vomiting.
GENERAL APPEARANCE:
alert of patient is reduce or
low ,uncooperative
1-skull
2-scalp
3-eyes
11-abdomen
4-nose
5-throat 12-upper and lower extremities

6-skin

7-neck region

8-lungs
9-heart
10-breast
 Body parts Technique used Actual finding Analysis

1-Skull Inspection, The skull is normocephalic and Normal

palpation symmetrical to the body with
prominences in frontal and
occipital area ,symmetrical in
all place.

2-Scalp Inspection White ,no mass, lumps, scar Normal

,and lesions no area of
tenderness is observed .
 Body parts Technique used Actual finding Analysis

3- Eyes Inspection Dilated pupils and no reaction to Not normal

light , she have some discharges indicates
around the lacrimal area . Low level of
conscious

4-Nose Inspection Midline symmetrical and patent , no Normal

discharge.
 Body parts Technique used Actual finding Analysis

5- Throat Inspection Oral cavity and pharynx Normal

normal. No inflammation,
swelling, exudate, or lesions.
Teeth and gingiva in good
general condition.

6- Skin Inspection , normal color, texture and Normal

palpation turgor
with no lesions or eruptions.

Generally uniform skin

temperature.
 Body parts Technique used Actual finding Analysis

7-Neck region Inspection , Symmetrical and straight Normal

palpation ,no palpable lumps, and
supple, trachea is on
midline of neck , and spaces
both sides. are equal on

8-Lungs Auscultation , Clear to auscultation and Normal

percussion percussion without rhonchi,
wheezing or diminished
breath sounds.
 Body parts Technique used Actual finding Analysis

9-Heart Auscultation Normal S1 and S2. No S3, S4 Normal

or murmurs. Rhythm is
regular. There is no
peripheral edema, cyanosis
or pallor. Extremities are
warm and well perfused.

10-Breast Inspection , No tenderness, Normal

Palpation Masses,
Nodules and discharge.
 Body parts Technique Actual finding Analysis
used

11-Abdomen Inspection , Positive bowel sounds. Soft, no Normal

Auscultation, distended, non tender. No
Percussion, guarding or
Palpation rebound. No masses, uniform
color ,rounded symmetrical

12-Upper and Inspection Both feet reveals all toes to be Normal

lower normal in size and symmetry, normal
extremities range of motion, normal sensation
with distal capillary filling of less
than 2 seconds without tenderness,
swelling, discoloration, nodules,
both ankles, knees, legs, and hips
reveals normal range of motion,
normal sensation without
tenderness, swelling, discoloration,
crepitus, weakness or deformity.
 Result: Normal Values:
Sodium: (1( 124 132-146mmol/L

Potassium : 4.2 3.6-5.0mmol/L

Chloride:(2 ( 92 98-107mmol/L
Enzymatic 25 22-29mmol/L
bicarbonate:

Hyponatremia 1

Hypochloremia 2
 Result: Normal Values:
WBC (1( 14.51 4.0-11.0 10^3/Ml
RBC 4.40 3.8-4.8 10^6/Ml
Hemoglobin 12.9 12.0-16.0g/dl
HCT 37.5 36.0-45.0%
MCV 85.2 82.7-89.4

MCHC 34.4 31.5-34.5g/dl

leukocytosis 1
Miscellaneous Chemistry

Result : Normal Values:

Magnesium 0.79 0.74-0.99mmol/L

Phosphate 1.01 0.81-1.58mmol/L

Calcium 2.33 2.12-2.52mmol/L

 Renal Function Test

Result: Normal Values:

Urea nitrogen 1.66 2.5-6.4mmol/L

Creatinine 37 53-155mmol/L
•Grade I or II SAH:
•In patients with a suspected grade I or II
subarachnoid hemorrhage (SAH), emergency
department (ED) care essentially is limited to
diagnosis and supportive therapy.
•Early identification of sentinel headaches is
key to reduced mortality and morbidity rates.
Use sedation judiciously.
•Secure intravenous access, and closely
monitor the patient's neurologic status
• Grade III, IV, or V SAH:
• In patients with a grade III, IV, or V subarachnoid hemorrhage (SAH) (ie,
altered neurologic examination), ED care is more extensive.
• Address the patient's airway, breathing, and circulatory status (ABCs). In
addition, reliable neurologic examinations before and after initial
treatment are critically important to optimizing management and to
deciding on the appropriate neurosurgical intervention.
• Intubation
• Endotracheal (ET) intubation of obtunded patients protects them from
aspiration caused by depressed airway protective reflexes. Also intubate
to hyperventilate patients with signs of herniation.
• Precautions
• Avoid excessive or inadequate hyperventilation. Target the partial
pressure of carbon dioxide (pCO2) at 30-35 mm Hg to reduce elevated
ICP. Excessive hyperventilation may be harmful to areas of vasospasm.
• Avoid excessive sedation. It makes serial neurologic exams more difficult
and has been reported to increase ICP directly. However, avoid any
increase in ICP due to excessive agitation from pain and discomfort.
• Neurosurgery to
• If no aneurysm is found, the person should be
closely watched by a health care team and may
need more imaging tests
• Treatment for coma or decreased alertness
includes:
• Draining tube placed in the brain to relieve
pressure
• Life support
• Methods to protect the airway
• Special positioning
•A person who is conscious may need to be
on strict bed rest. The person will be told to
avoid activities that can increase pressure
inside the head, including:
•Bending over
•Straining
•Suddenly changing position
•Treatment may also include:
•Medicines given through an IV line to
control blood pressure
•Nimodipine to prevent artery spasms
•Painkillers and anti-anxiety medications to
relieve headache and reduce pressure in the
skull
•Phenytoin or other medications to prevent
or treat seizures
•Stool softeners or laxatives to prevent
straining during bowel movements
Adjunctive Therapies and Measures
• Keep the patient's core body temperature at 37.2°C
• Consider antiemetics for nausea or vomiting.
• Elevate the head of the bed 30° to facilitate
intracranial venous drainage. Emergent ventricular
drainage by the neurosurgeon may be necessary.
• Maintain the patient's serum glucose level at 80-120
mg/dL; use sliding or continuous infusion of insulin if
necessary.
• Fluids and hydration
• Do not over hydrate patients because of the risks of
hydrocephalus.
• Patients with subarachnoid hemorrhage (SAH) may
also have hyponatremia from cerebral salt wasting.
In our case :
•Investigation :
•CBC analysis
•Urine analysis
•Pt ,PTT

•Diagnostic procedures :
•ECG
•CT brain
•MRI
• chest x ray
Special order :

•Elevate the head of the bed 30° .

•Normal saline 70ml \hour
•Regular soft diet
•Keep oxygen saturation between 95 to 98 % .
DRUG STUDY
 DRUG NAME DOSAGE/ INDICATIONS/ SIDE EFFECTS NURSING RESPONSIBILITIES
ROUTE/ CONTRAINDICATION
FREQUENCY

GENERIC ROUTE -INDICATIONS Minimal GI upset. Do not exceed 4gm/24hr. in adults

NAME: IV Analgesic-antipyretic in Methemoglobinemia Do not take for 10 days for pain in adults,
or more than 3 days for fever in adults.
Paracetamol DOSAGE patients with aspirin Hemolytic Anemia
Extended-Release tablets are not to be
60mg allergy, hemostatic Neutropenia chewed.
FREQUENC disturbances, bleeding Thrombocytopenia Monitor CBC, liver and renal functions.
BRAND
Y diatheses Pancytopenia Assess for fecal occult blood and nephritis.
NAME Q6h CONTRAINDICATION Leukopenia Avoid using OTC drugs with
Acetaminophen Acetaminophen.
Renal Insufficiency Urticaria
Take with food or milk to minimize GI
Anemia CNS stimulation
CLASSIFICATION upset.
Special Concerns: Hypoglycemic coma Report N&V. cyanosis, shortness of breath
Analgesics
Liver toxicity (hepatocyte Jaundice and abdominal pain as these are signs of
(nonopioid) -
necrosis) Glissitis toxicity.
Muscle
Drowsiness Report paleness, weakness and heart beat
Relaxants -Anti- skips
Liver Damage
pyretic Report abdominal pain, jaundice, dark
.
urine, itchiness or clay-colored stools.
Phenacetin may cause urine to become
dark brown or wine-colored.
Report pain that persists for more than 3-5
days
Avoid alcohol.
This drug is not for regular use with any
form of liver disease.
 DRUG NAME DOSAGE/ INDICATIONS/ SIDE EFFECTS NURSING RESPONSIBILITIES
ROUTE/ CONTRAINDICATION
FREQUENCY
GENERIC ROUTE -INDICATIONS Gastrointestinal - Assess patient for pain and
NAME: IV prescribed for painful Abdominal discomfort, limitation of movement; note
Nimesulide DOSAGE Relieve pain after heartburn, abdominal type, location, and intensity
40MG surgical intervention cramps, nausea, prior to and at the peak
FREQUENCY inflammatory conditions vomiting and diarrhea. following administration.
BRAND OD Central Nervous Administer after meals or with
NAME System - Headache, food or an antacid to minimize
Nexen CONTRAINDIC dizziness and gastric irritation.
ATION to patients with drowsiness. Instruct patient to take with a
CLASSIFICATION gastrointestinal bleeding, full glass of water and to remain
Analgesic, antipyretic ulcer, severe kidney, liver Genitourinary - Blood in an upright position for 15-30
Non steroidal Anti- disease, bleeding in urine, decrease in min after administration.
Inflammatory Agents disorders, and urination and kidney Teach patient to report blurred
NSAID hypersensitivity failure. vision, ringing of ears that may
indicate toxicity.
Advise patient to report change
in urine pattern, edema,
increased pain in joints, fever,
blood in urine that may indicate
nephrotoxicity
DRUG NAME DOSAGE/ INDICATIONS/ SIDE EFFECTS NURSING RESPONSIBILITIES
ROUTE/ CONTRAINDICATION
FREQUENCY

GENERIC ROUTE -INDICATIONS Abdominal Assess condition before therapy and

NAME: Po Prevention and discomfort reassess regularly thereafter to monitor
Lactulose DOSAGE treatment of portal- associated with drug’s effectiveness>
15 ML systemic encephalopathy Flatulence and Monitor pt for any adverse GI
FREQUENCY (PSE), including stages of intestinal cramps. reactions,nausea,vomiting,diarrhea,>
BRAND OD hepatic precoma and Nausea,vomiting, Assess for adverse reactions>
NAME coma diarrhea on for pt. with hepatic encephalopathy
Cephulac CONTRAINDIC prolonged use. :regularly assess mental condition>
ATION to monitor I & O>
CLASSIFICATION Patients who require a monitor for Inc.glucose level in diabetic
hyperosmotic low galactose diet pts
laxative
Nursing managment
assessment scientific Nursing diagnosis palnning intervention evaluation
explanation
Subjective:I have a leakage of blood Acute pain related after 3hrs of -Assess for signs and Evaluate
severe headache” from an aneurysm to stretching or nursing symptoms of headache patient
as verbalized by in the brain compression of intervention (statements of same, pain scale if
patient cerebral vessels the patient restlessness, irritability, it is
Objective: and tissue will reduce grimacing, rubbing head, reduced or
Behavior: showing associated with of pain as avoidance of bright lights and not.
symptoms pain. accumulation of increased evidenced noises, reluctance to move)
Changes in the blood between the intracranial by: Rational:to assess whether the
ability to perform arachnoid and pia pressure 1. client felt the pain of acute or
daily activities. mater verbalization chronic
pain scale:5of 10 . of the same -Assess patient's perception
2. relaxed of the severity of the
elevation of the headache using a pain
facial
pressure in the
expression intensity rating scale.
cranium
and body Rational:It is important to
positioning help patients express as
factually as possible
- Assess the patient's pain
pattern
(e.g. location, quality, onset,
duration, precipitating factors,
aggravating factors, alleviating
factors).
Rational:Different etiologic
factors respond better to
different therapies
intervention

-Assess the degree of making a false step in person from the patient, such
as isolating themselves,Note the influence of pain such as: loss of interest
in life, decreased activity, weight loss
Position patient in semi fowler position.
Rational:Pain that has been chronic and long-standing may have
devastating emotional effects on the patient and these emotional
complications may make effective treatment of the pain more difficult.
-Encourage patient to rest in bed.
Rational:to reduce the intensity of pain.
-Provide quite and calm environment.
-Teach relaxation and deep breathing techniques
Rational:to reduce tension and create a feeling more comfortable.
-Give the hot moist compress / dry on the head, neck, arms as needed.
Rational:Hot moist compresses have a penetrating effect. The warmth
rushes blood to the affected area to promote healing
Massage the head / neck / arm if the patient can tolerate the touch.
Rational:to decreases muscle tension and can promote comfort
-Use the techniques of therapeutic touch, visualization, and stress
reduction and relaxation techniques to another.
Rational:Techniques used to bring about a state of physical and mental
awareness and tranquility. The goal of these techniques is to reduce
tensions, subsequently reducing pain.
-Instruct the patient to use a positive statement "I am cured, I'm relaxing, I
love this life“, Instruct the patient to be aware of the external-internal
dialogue and say "stop" or "delay" if it comes up negative thoughts.
Collaboration for providing analgesic as doctor order..
Rational:The use of a mental picture or an imagined event that involves
use of the five senses to distract oneself from painful stimuli.
assessment scientific Nursing palnning intervention evaluati
explanation diagnosis on
Subjective: the inadequacy of Ineffective After 2 hr patient Assess factors related to
“Why am I here, blood flow Cerebral will able to individual situation for decreased After 2
what happened to through the Tissue Maintain improved cerebral perfusion and potential hr
me "as verbalized cerebral Perfusion level of for increased ICP. Cerebral
by patient vasculature to related to consciousness, Rationale: Assessment will function
maintain brain hemorrhage cognition, and determine and influence the improve
Objective: function sensory function. choice of interventions. d;
-Altered level of Deterioration in neurological neurolog
consciousness; signs or failure to improve after ical
-Changes in initial insult may reflect deficits
sensory responses decreased intracranial adaptive stabilized
capacity requiring patient to be .
transferred to critical area for
monitoring of ICP, other
therapies.
intervention

-Closely assess and monitor neurological status frequently and compare with baseline.
Rationale: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in
determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of
impending thrombotic CVA.
-Evaluate pupils, noting size, shape, equality, light reactivity.
Rationale: Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining
whether the brain stem is intact. Pupil size and equality is determined
-Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.
Rationale: Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice
of interventions.
Assess higher functions, including speech, if patient is alert.
Rationale: Changes in cognition and speech content are an indicator of location and degree of cerebral
involvement and may indicate deterioration or increased ICP.
-Position with head slightly elevated and in neutral position.
Rationale: Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing
interventions and provide rest periods between care activities. Limit duration of procedures.
Rationale Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may
be needed to prevent rebleeding in the case of hemorrhage
Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity
Rationale: Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased
ICP or cerebral injury, requiring further evaluation and intervention.
Administer supplemental oxygen as indicated.
Rationale: Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema
formation.
assessment Nursing intervention Planning intervention evaluatio
n

Ineffective Coping Assess extent of altered perception After 1

Subjective: related to vulnerability, and related degree of disability. hour
Inability to make cognitive perceptual After 1 hour Determine Functional Independence Patient
decisions changes. Patient Verbalize Measure score. was able
acceptance of self in acceptan
situation and Verbalize Rationale: Determination of ce of self
Objective: awareness of own individual factors aids in developing in
Inability to coping abilities. plan of care/choice of interventions situation
cope/difficulty asking and discharge expectations. and
for help awarenes
s of own
Determine outside stressors: family, coping
work, future healthcare needs. abilities

Rationale: Helps identify specific

needs, provides opportunity to offer
information and begin problem-
solving. Consideration of social
factors, in addition to functional
status, is important in determining
appropriate discharge destination.
assessment Nursing intervention planning intervention evaluation

Encourage patient to express feelings,

including hostility or anger, denial ,
depression, sense of disconnectedness

Rationale: Demonstrates acceptance

of patient in recognizing and beginning to
deal with these feelings.

Identify previous methods of dealing with

life problems. Determine presence of
support systems.

Rationale: Provides opportunity to use

behaviors previously effective, build on past
successes, and mobilize resources.

Monitor for sleep disturbance, increased

difficulty concentrating, statements of
inability to cope, lethargy, withdrawal.

Rationale: May indicate onset of depression,

which may require further evaluation and
intervention
assessment Nursing intervention planning intervention evaluation

Refer for
neuropsychological
evaluation and/or
counseling if indicated.

Rationale: May
facilitate adaptation to
role changes that are
necessary for a sense
of feeling/being a
productive person.
Discharge Plan
• Activity
 You will need to have someone with you for the next several days to
watch for worsening of symptoms (see below) and to allow you to rest.
 Start with light activity around the house for the first 3 days you are
home.
 Gradually increase your activity starting with short walks 1-2 times
per day.
 Avoid contact sports, skating, bike riding, or other such activities for 6
weeks.
Encourage pt to do passive range of motion
• Nutrition :
Instruct the relative to feed pt on time with proper food low in Na
Low in cholesterol low in fat and give citrus fruits ,moderate in fluid
intake and increase fiber diet to improve health.
 Ffollow the diet prescribed by the doctor.
Medications
 Take your medications as prescribed and
gradually decrease pain medications as your pain
improves.
Instruct pt and their relative to follow medication
regimen
Educate and instruct the patient and her family to
monitor BP and PR before giving medication
Follow-up
Follow up with your primary care physician for all
medical issues.
 Call your doctor or return to the emergency room if
you experience any of the following symptoms:
. • Clear or bloody drainage from your nose or ears
• Worsening headache
• Changes in vision or differently sized pupils
• Seizure activity or jerking / twitching of the face, arms, or legs
• Sleepiness or difficulty waking up
• Memory loss
• Irritability
• Nausea or vomiting that won’t stop
• Confusion or difficulty talking
• A fever above 100 degrees F
• Arm, leg, or facial weakness
• Difficulty walking, loss of balance, and dizziness
• Stiff neck
• Subarachnoid hemorrhage (SAH) is a pathologic condition
that exists when blood enters the subarachnoid space

• The most common cause of SAH is trauma

• The most common cause of spontaneous SAH is an

aneurysmal bleed (65-80%)

• •Sudden explosive headache may be the only symptom in a

third of patients.

•Of patients who present with a sudden explosive headache

as the only symptoms, around 10% have SAH
References:

• Naggara ON, White PM, Guilbert F, et al. Endovascular

treatment of intracranial unruptured aneurysms: systematic
review and meta-analysis of the literature on safety and
efficacy. Radiology. 2010;256:887-897.
• Reinhardt MR. Subarachnoid hemorrhoid. J Emerg Nurs.
2010;36:327-329.
• Tateshima S, Duckwiler G. Vascular diseases of the nervous
system: intracranial aneurysms and subarachnoid
hemorrhage. In: Daroff RB, Fenichel GM, Jankovic J,
Mazziotta JC. Bradley’s Neurology in Clinical Practice. 6th ed.
Philadelphia, PA: Elsevier Saunders; 2012:chap 51C.
• Zivin J. Hemorrhagic cerebrovascular disease. In: Goldman L,
Schafer AI, eds. Goldman's Cecil Medicine. 24th ed.
Philadelphia, PA: Elsevier Saunders; 2011:chap 415.
• http://www.strokecenter.org/professionals/brain-
anatomy/blood-vessels-of-the-brain/
THANK
YOU