What is the management for a subarachnoid hemorrhage adjacent to the anterior falx after a fall?

Management of Subarachnoid Hemorrhage Adjacent to the Anterior Falx After a Fall

Traumatic subarachnoid hemorrhage (SAH) adjacent to the anterior falx requires prompt neurosurgical evaluation, blood pressure control with systolic targets >110 mmHg but <150 mmHg, and close monitoring for neurological deterioration to optimize outcomes.

Initial Assessment and Stabilization

Immediate Evaluation

• Determine Glasgow Coma Scale (GCS) score - this is the most important predictor of outcome 1
• Assess for indications for immediate intubation:
  • GCS ≤ 8
  • Deteriorating consciousness (fall in GCS by ≥2 points or motor score by ≥1 point)
  • Loss of protective laryngeal reflexes
  • Respiratory compromise (PaO₂ < 13 kPa or PaCO₂ > 6 kPa)
  • Seizures
  • Bilateral mandibular fractures or copious oral bleeding 1

Imaging Studies

• Non-contrast head CT is the cornerstone of SAH diagnosis with 98-100% sensitivity in first 12 hours 1
• If initial CT is negative but clinical suspicion remains high, perform lumbar puncture to look for xanthochromia 1
• CT angiography (CTA) to evaluate for underlying vascular abnormalities
• Consider digital subtraction angiography (DSA) with 3D rotational angiography if CTA is negative or inconclusive 1

Blood Pressure Management

Target Parameters for Traumatic SAH

• Maintain systolic BP >110 mmHg and MAP >90 mmHg
• Keep systolic BP <150 mmHg if within 6 hours of symptom onset and immediate surgery not planned 1
• Use titratable agents to balance risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure 1
• Monitor BP closely - preferably with arterial line placement at the level of the tragus 1

Specific Management Steps

Aneurysm Evaluation and Treatment (if identified)

• Multidisciplinary evaluation by neurosurgical and endovascular specialists 1
• For anterior circulation aneurysms amenable to both approaches, endovascular coiling is preferred over clipping to improve 1-year functional outcomes 1
• For posterior circulation aneurysms, coiling is strongly indicated over clipping 1
• If large intraparenchymal hematoma is present with depressed consciousness, emergency clot evacuation should be performed 1

Prevention of Secondary Brain Injury

• Maintain euvolemia and normal circulating blood volume 1
• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days to improve neurological outcomes (not for vasospasm prevention) 2
• Maintain PaCO₂ between 4.5-5.0 kPa 1
• Ensure adequate oxygenation with PaO₂ ≥13 kPa 1
• Avoid hyperglycemia, acidosis, electrolyte abnormalities, and hyperthermia 1

Management of Hydrocephalus (if present)

• Perform urgent CSF diversion via external ventricular drainage (EVD) or lumbar drainage for acute symptomatic hydrocephalus 1
• Consider permanent CSF diversion for chronic symptomatic hydrocephalus 1

Monitoring for Complications

• Monitor for delayed cerebral ischemia (DCI) which typically develops 3-14 days after SAH
• If DCI occurs, induce hypertension unless contraindicated by cardiac status or baseline hypertension 1
• Consider cerebral angioplasty and/or selective intra-arterial vasodilator therapy for symptomatic vasospasm not responding to hypertensive therapy 1
• Implement venous thromboembolism prophylaxis after aneurysm is secured 1

Special Considerations

Transfer Decisions

• Consider early transfer to high-volume centers (>35 SAH cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurocritical care services 1
• Low-volume hospitals (<10 SAH cases per year) should particularly consider transfer 1

Pitfalls to Avoid

• Do not induce hypervolemia as it is potentially harmful 1
• Avoid phenytoin for seizure prophylaxis as it is associated with excess morbidity and mortality 1
• Do not administer routine IV magnesium or statins as they do not improve outcomes 1
• Never administer nimodipine intravenously as it can cause significant hypotension 2
• Avoid delays in diagnosis - SAH is frequently misdiagnosed, leading to 4-fold higher likelihood of death or disability 1

By following this management approach, you can optimize outcomes for patients with traumatic subarachnoid hemorrhage adjacent to the anterior falx after a fall, focusing on preventing rebleeding, managing intracranial pressure, and avoiding secondary brain injury.