A case report on Sub Arachnoid Hemorrhage (SAH)

R. Kaviya1, N. Suma2, S J. Soniya mercy Anbu3, R. Ruby4

1Staff nurse-ER, MAA Kauvery Hospital, Trichy, Tamil Nadu

2Senior staff nurse-ER, MAA Kauvery Hospital, Trichy, Tamil Nadu

3Nursing Educator, MAA Kauvery Hospital, Trichy, Tamil Nadu

4Senior DNS, MAA Kauvery Hospital, Trichy, Tamil Nadu

Case Presentation

A 6 years old male child premorbidly well and developmentally normal, brought with alleged history of RTA (4 wheeler collided with tree), sustaining head injury associated with LOC for around 2 hours and regained consciousness twice in between for short periods. Baby has got small incised wound in right forearm and small abrasion in the mucosal part of upper and lower lips. On presenting to ER, child was lethargic with a GCS of E2 V1 M4, pupil 2mm RTL bilaterally, exaggerated DTR, weak peripheral pulse and hypotension. Child developed seizure, and was not settled with medications and later the seizure got aborted. Child was intubated with cervical spine stabilization and connected to mechanical ventilation in view of poor sensorium, pulse volume and BP.

Clinical findings

Child on mechanical ventilation

Pulse volume – weak peripheral pulse

Temp: 98.6’F

HR: 105/mt

RR: 30/mt

SPO2: 98% with mechanical ventilation

BP:80/50 mmHg

Systemic examination

CNS: GCS-E2 V1 M4

Pupil B/L 2mm RTL

Tone-Normal

DTR-Exaggerated in all limbs

Plantar-mute bilaterally

R/S: B/L Air entry- equal

P/A: Soft, non-tender

CVS: S1 and S2 heard

Anthropometry MeasurementCentile
Weight14.2kg50th - 75th percentile
Height98CM3rd to 10th percentile
BMI21.2650th - 75th percentile

Inference: Normal

Past history

Nil significant

Development history

Going to school (UKG), his scholastic performance is good.

Immunization history

Immunized till date.

Diagnosis

  • Road traffic accident
  • Traumatic brain injury-SAH left parietal region/multifocal
  • Hemorrhagic contusion
  • Left forearm incised wound

Clinical signs and symptoms

  • Loss of consciousness around 2 hours
  • Sustaining head injury
  • Small incised wound over inner aspect of(R) forearm
  • Small abrasion in mucosal part of both upper and lower lip

CT brain (plain)

  1. Hyperdensity present in the sulcal spaces of the parietal region.
  2. Left parietal SAH present

MRI brain with C-spine Screening

Multifocal hemorrhagic contusion in left basifrontal, anterior temporal cortex, bilateral fronto-parietal and corpus callosum with interhemispheric fissure SAH/ no evidence of spine injury.

Lab investigations

DateInvestigationsValues
05.07.2025 Hemoglobin 9.8 g/dl
5.07.20025 Packed cell volume29.5%
05.07.2025 RBC Count3.84 10^9/cumm
05.07.2025 Total WBC count19480 cells/cumm
05.07.2025 Absolute neutrophil count 16280 cells/mul
05.07.2025Absolute monocyte count1340 cells/mul
05.07.2025Platelet count3080000 cells/mul
05.07.2025sodium140 mmol/L
05.07.2025Potassium3.44mmol/L
05.07.2025Chloride110mmol/l
05.07.2025Bicarbonate19.0mmol/L
08.07.2025Haemoglobin9.3g. dl
08.07.2025Packed cell volume(PCV)27.6%

Opinion

OpinoinDoctorReason
Neuro surgeonDr. MadhusuthanTraumatic brain injury

Treatment given

  • IV Fluids
  • Levipil
  • Midazolam
  • Paracetamol
  • Fentanyl
  • Pan
  • Xone
  • Nor adrenaline
  • 3 % sodium chloride
  • Clindamycin
  • Urilizer
  • Dexa
  • levipil

Course in the Hospital

  • On presenting to ER, child was lethargic with a GCS of E2V1M4, pupil 2mm RTL bilaterally, exaggerated DTR, weak peripheral pulse and hypotension.
  • After 5 min of arriving ER, child developed seizure, and was not settled with inj lorazepam then loaded with levipil and seizure got hypotension.
  • Child was intubated with cervical spine stabilization and connected to mechanical ventilation in view of poor sensorium, pulse volume and BP improved after NS bolus.
  • Child was started on IV sedation, IVF, IV anticonvulsants and analgesics.
  • Hypertonic saline bolus was given i/v/o raised ICP.  POCUS of heart, lung and abdomen were normal. Child was shifted to PICU.
  • CT Brain Plain showed thin SAH in left parietal region. Neuro surgeon opinion was obtained and advised conservative management.
  • Blood investigations showed anemia and leucocytosis. RFT and Serum electrolytes were normal.
  • Mechanical ventilation, sedoanalgesia, IV fluid, IV anticonvulsants and analgesics were continued. Optic nerve sheath diameter was high hence Ist line anti raised ICP measures were strictly followed.
  • Started on 3% Nacl infusion.Cervical collar was applied, CVC was secured and invasive BP monitoring was done.
  • Repeat POCUS lung showed right lower lobe collapse and features s/o aspiration, hence antibiotic was added.
  • Child was started on noradrenaline infusion to maintain MAP > 50th centile for age. Suturing of wound over right forearm was done. NG feeds were started and gradually hiked up to maximum.
  • Child sensorium improved over next 48 hours, responding to name with partial eye opening.
  • Child was given spontaneous breathing trial on day 3 OD PICU stay, tolerated well and extubated and connected to High flow nasal cannula.
  • *There were no signs of respiratory distress; HFNC was gradually weaned to room air. However, there was no further improvement in sensorium and child remain encephalopathic, hence MRI brain with C-spine screening was done.
  • Child sensorium started improving in next 24 hours, recognizes parents, orally accepting well, can walk without support, was hemodynamically stable, and hence was shifted to HDU and eventualy to ward.
  • The child remained asymptomatic and hemodynamically stable during ward stay. Hence child is discharged with following advice.

Condition at discharge

Child was symptomatically better, vitals stable, general condition good, hence discharged home with following advice and review in OPD.

Advice on discharge

S. No Drug name Route Frequency
1Syp. levipiloral To continue
2Syp. hemozinkoral3 months
3Tab. zincovitoral2 weeks

Advised the parents to bring the child to hospital immediately if symptoms of excessive dullness, cough, cold, fever, fast breathing, excessive vomiting, excessive diarrhea, decrease urine output.

Discussion

Introduction

Subarachnoid hemorrhage is bleeding into the arachnoid membrane and the pia mater surrounding the brain and spinal cord. This space contains cerebrospinal fluids (CSF).

Definition

A subarachnoid hemorrhage is bleeding in the space between the brain and the thin tissues that cover the brain (called the subarachnoid space). It is a serious, life-threatening condition.

Etiology

Traumatic SAH

  • Head injury due to fall
  • Assault
  • Motor vehicle accident

Non-Traumatic (Spontaneous) SAH

  • Aneurismal rupture (85%of non-traumatic causes)
  • Berry aneurysms (common in circle of willis)
  • Arteriovenous malformations (AVM)
  • Mycotic aneurysms(infection)
  • Coagulapathy
  • Cerebral venous thrombosis
  • Neoplasm associated bleeding
  • Idiopathic

Risk factors

  • Hypertension
  • Smoking
  • Family history of Aneurysm
  • Polycystic kidney disease
  • Connective tissue disorder (e.g. Ehlers-panlos syndrome)
  • Excess alcohol intake
  • Use of cocaine or Amphetamines

Pathophysiology

Clinical features

Kernig’s sign

Resistance of pain when trying to extend the knee with the hip flexed at 90 degrees.

Brudzinski’s sign

  • Involuntary lifting of the legs when the neck is flexed
  • Neck Stiffness
  • Nausea and Vomitting
  • Sudden Thunder clap head ache
  • Photophobia
  • Reastlessness and Agitation
  • Seizure

Diagnostic evalaution:

  • Non contrast CT brain
  • CT angiography
  • MRI/MRA
  • Ancillary test: CBC, Electrolytes, ECG
  • Lumbar puncture.

Management

  • Initial stabilization: Airway, breathing, Circulation
  • Blood pressure Control (Labetalol, Nifidipine )
  • Nimodipine 60mg (To Prevent vasospasm)
  • Anti-Convulsant if Seizure
  • Fluid management: Maintain normal volume status
  • Avoid Dehydration
  • Use Isotonic Fluid
  • Monitor urine output and electrolytes
  • Surical management: Surgical clipping -Repair of Aneurysm (Metal clip placed across Aneurysm)
  • Endovascular coiling: Repair of deep Aneurysm (Platinum coils placed inside Aneurysm through Femoral artery)
  • Complication Management: Vasospasm (4 to 14 days) monitor with Tran cranial Doppler
  • Hydrocephalus- Ventriculostomy or VP Stunt
  • Hyponatremia- often due to cerebral salt wasting or syndrome of apparent inappropriate anti diuretic hormone secretion
  • Rehabilitation and long term follow-up: Begin early physiotherapy, cognitive therapy
  • Monitor for Mood Disorder, Cognitive impairment
  • Follow up Imaging to assess Aneurysm status (MRI/MRA).

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