[ Neurosurgery ] SAH 3

WFNS grades 1 to 3

Grade 1 GCS 15 without motor deficit, grade 2 GCS 13 to 14 without deficit, grade 3 GCS 13 to 14 with motor deficit.

Hunt and Hess scale – basis and use

Symptoms and neurological status, used to estimate survival.

Hunt and Hess – grades 1 to 3

Grade 1 asymptomatic or mild headache (70% survival), grade 2 moderate to severe headache with no deficit except CN palsy (60%), grade 3 drowsiness or confusion.

Fisher grading – basis and use

Radiological (CT based), predicts vasospasm.

SAH – emergency stabilization

ICU admission, ABC with ICP reduction, intubation if GCS 8 or less, and arterial and venous catheters.

SAH – monitoring

Hourly neuro checks and vitals, with EVD if hydrocephalus.

SAH – supportive drugs

Analgesia (codeine or morphine), stool softeners, and H2 blockers or PPI.

SAH – steroid use

Dexamethasone may help headache and neck pain.

SAH – preventing rebleeding

Definitive repair of the aneurysm and avoiding or reversing anticoagulants and antiplatelets.

Unsecured aneurysm – BP management

Keep SBP at 120 to 140 (high rebleeding risk), with gentle volume expansion.

Secured (clipped) aneurysm – BP management

Aggressive 3H protocol (hypertension, hypervolemia, hemodilution), SBP 140 to 160 (permissive HTN).

Vasospasm – prevention

3H protocol plus calcium channel blockers.

Surgical clipping – role and method

Optimal definitive management, via open craniotomy.

Surgical clipping – advantage and goal

Permanent exclusion of the aneurysm, preventing rupture or enlargement while minimizing brain injury.

Endovascular coiling – method

Platinum coils fill the aneurysm sac to induce thrombosis.

Endovascular coiling – pros and cons

Minimally invasive with shorter recovery, but high recurrence risk, and a stent may be needed.

Factors favoring coiling (examples)

Dome-to-neck ratio 2 or more, neck under 5 mm, and multiple aneurysms not treatable with the same approach.

Factors favoring clipping (examples)

Giant (over 20 to 25 mm) or small (under 1.5 to 2 mm) aneurysms.

SAH surgery – early timing

Within 3 days (best), reduces rebleeding risk and facilitates vasospasm treatment.

SAH early surgery – arguments against

Swollen, hyperemic brain, and surgery may increase vasospasm