Neurocritical Care

Serial neurologic examination

NIH Stroke Scale and/or GCS score

Score Range

Comments

Hunt and Hess

0 (no symptoms) to 5 (moribund)

Best correlated with risk of mortality

World Federation

of Neurological

Surgeons

1 (GCS score 15, no deficit) to 5 (GCS score 3–6)

Integrates risk of mortality and

motor dysfunction

Fisher

1 (no blood visualized) to 4 (diffuse SAH, ICH,

or intraventricular hemorrhage present)

Best correlated with risk of

vasospasm

CT scan of brain

Digital subtraction (“conventional”) angiography

May use CT angiography or magnetic resonance angiography if conventional angiography is unavailable

Transcranial Doppler, often daily during peak vasospasm risk period

INR

Troponin

ECG (electrocardiogram)

Echocardiogram

Causes – Typically caused by cerebral aneurysm. Modifiable risk factors for SAH:

Hypertension

Illicit drug use

Sudden death: Around 22%–26% of patients die before hospitalization. Inpatient mortality 13.1% in

2018 (United States).

Presence of blood in subarachnoid space elicits a chemical meningitis-type inflammatory response

and results in hemolysis of subarachnoid blood.

Vasospasm (persistent vasoconstriction) occurs, reducing distal cerebral blood flow.

Typical course is 3–14 days, but can occur out to 21 days post ictus.

ii.

Vasospasm risk peaks at around 7–10 days.

Several mechanisms of pathogenesis

Inflammatory infiltration