PEA cardiac arrest, preceded by a history of occiptal headache and neck pain. Intracerebral haemorrhage?
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There is diffuse subarachnoid haemorrhage within the basal cisterns, sulci and all ventricles. There is a 12 mm rounded high attenuation area centred on the left MCA probably representing an MCA aneurysm.
The optic nerves appear thickened bilaterally likely secondary to papilloedema. In addition, there is a high attenuation area within the left posterior globe likely reflecting haemorrhage, Terson syndrome.
No tonsillar or uncal herniation. There is widespread sulcal effacement.
Opinion: Extensive, diffuse subarachnoid haemorrhage likely secondary to left MCA aneurysm rupture.
This case shows an extensive subarachnoid haemorrhage with blood in the posterior globe. The combination of these features is known as Terson syndrome.
Subarachnoid haemorrhage has multiple grading systems, both clinically and radiologically based:
- I – no blood
- II – diffuse deposition of SAH without clots or layers of blood >1mm
- III – localized clots and/or vertical layers of blood 1mm or > thickness
- IV – diffuse or no subarachnoid blood but intracerebral or intraventricular clots
Validated to predict the likelihood of vasospasm.
Claassen Scale (2004)
- 5 grades
Predicts the risk of delayed cerebral ischemia, combines additive risk from SAH and IVH.
Ogilvy and Carter (1998)
- combines clinical and radiological findings
- combination of age, Hunt-Hess grade, Fisher grade, and aneurysm size and age
- studies of this are flawed
- minimal inter-observer variability
- Nickson, C. (2017) Subarachnoid Haemorrhage Grading Systems, LITFL: Life in the Fast Lane Medical Blog. Available at: https://lifeinthefastlane.com/ccc/subarachnoid-haemorrhage-grading-systems (Accessed: 19 March 2017).
- Swallow CE, Tsuruda JS, Digre KB et-al. Terson syndrome: CT evaluation in 12 patients. AJNR Am J Neuroradiol. 1998;19 (4): 743-7. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- Ness T, Janknecht P, Berghorn C. Frequency of ocular hemorrhages in patients with subarachnoidal hemorrhage. Graefes Arch. Clin. Exp. Ophthalmol. 2005;243 (9): 859-62. doi:10.1007/s00417-005-1131-z - Pubmed citation
- Van gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain. 2001;124 (Pt): 249-78. doi:10.1093/brain/124.2.249 - Pubmed citation