3.7 Management of subarachnoid haemorrhage

The incidence of subarachnoid haemorrhage (SAH) has been declining in the UK and Ireland (Kelly et al, 2012) and mortality has improved significantly in recent years with improvements in diagnosis and management (Mukhtar et al, 2016). SAH still accounts for approximately 5% of all acute strokes. 10–15% of those affected die before reaching hospital and overall survival is about 70%, but amongst patients admitted to a neurosurgical unit with a confirmed aneurysm, 85% will survive (Society of British Neurosurgeons, 2006). Case fatality and unfavourable outcomes rise with age and are highest in the over 65 age group (Society of British Neurosurgeons, 2006), and in those patients of a ‘poor clinical grade’ (Hunt and Hess or World Federation of Neurological Surgeons grades 4 & 5). Recurrent haemorrhage from the culprit aneurysm is the most frequent cause of death after the initial presentation. Diagnosis, referral to a tertiary centre and treatment to prevent rebleeding are therefore urgent. CT scanning is the most sensitive method to detect subarachnoid blood but when CT is negative lumbar puncture for xanthochromia after 12 hours may still be required, particularly if there has been a delay in presentation, as the sensitivity of CT for SAH declines with time from ictus. Usually non-invasive angiography (CT or MR) is required prior to intra-arterial angiography undertaken in the referring or neurosciences centre. After SAH many patients will have residual disability requiring neurorehabilitation and most will experience long-term symptoms, especially fatigue and cognitive disability. [2016]