Nonaneurysmal Subarachnoid Hemorrhage: A Review of Clinical Course and Outcome in Two Hemorrhage Patterns

Linda L. Herrmann; Joseph M. Zabramski


J Neurosci Nurs. 2007;39(6):135-142. 

In This Article

Abstract and Introduction

Patients who experience a nonaneurysmal subarachnoid hemorrhage differ from patients who suffer an aneurysmal subarachnoid hemorrhage in initial presentation (including neurological examination and computed tomography [CT] scans), clinical course, and outcome. A perimesencephalic distribution of nonaneurysmal subarachnoid blood on CT imaging has been described as a distinct clinical entity with a benign course and an excellent prognosis; research suggests that the majority of these patients have excellent outcomes. In most cases, these patients return to their previous level of functioning. Surviving a subarachnoid hemorrhage can be emotionally devastating to patients and their families and can threaten employment and health insurance eligibility. Using evidence-based practice, neuroscience nurses can reassure and educate patients, staff members, and the public and facilitate their understanding of the clinical course and outcome.

Patients who experience a spontaneous nonaneurysmal subarachnoid hemorrhage (NASAH) differ from patients who suffer an aneurysmal subarachnoid hemorrhage (ASAH) in their presenting symptoms, clinical course, and outcomes. Rupture of an aneurysm is typically associated with significant morbidity and mortality. Up to 20% of patients die as a result of their initial hemorrhage. Of those who survive, about half will have a poor outcome. Complications related to aneurysmal rupture depend on clinical grade, the extent of subarachnoid hemorrhage (SAH), and the presence of delayed cerebral ischemia (Adams, Kassell, Torner, & Haley, 1987; Hasan, Vermeulen, Wijdicks, Hijdra, & van Gijn, 1989; Jane, Kassell, Torner, & Winn, 1985; Kassell, Sasaki, Colohan, & Nazar, 1985). Patients who survive the rupture of an aneurysm are often faced with a lengthy hospital stay that centers on hemodynamic monitoring, hyperdynamic therapy, and management of hydrocephalus, hyponatremia, and other complications. Following the acute care stay, most patients require formal therapies to address mobility and cognitive deficits. After hospital discharge, patients and their families must manage many issues: the need for supervision of the patient; the loss of the patient's ability to drive, live alone, manage finances, or return to work; and the risk of recurrent ASAH.

In contrast, patients with a NASAH tend to make an excellent recovery. The pattern of hemorrhage in this group has been reported to correlate with clinical course and patient outcome (Alexander, Dias, & Uttley, 1986; Brilstra, Hop, & Rinkel, 1997; Rinkel et al., 1990; Rinkel, Wijdicks, Hasan et al., 1991; Rinkel, Wijdicks, Vermeulen et al., 1991). Within this group, two distinct hemorrhage patterns have been described: an aneurysmal hemorrhage pattern and a perimesencephalic hemorrhage pattern. The recognition of perimesencephalic SAH as a subgroup with a benign clinical course has provided clinicians with valuable information that directly influences patient care and education. In general, patients with perimesencephalic SAH have a better clinical grade upon presentation and little to no hydrocephalus or delayed cerebral ischemia. Most of these patients return rapidly to their premorbid level of functioning and employment (Alexander et al.; Brismar & Sundbarg, 1985; Rinkel et al., 1990; Rinkel, Wijdicks, Hasan, et al.; Rinkel, Wijdicks, Vermeulen, et al., 1991; van Gijn, van Dongen, Vermeulen, & Hijdra, 1985).

This article describes the two distinct patterns of spontaneous and angiographically negative NASAH: the perimesencephalic hemorrhage pattern and the aneurysmal hemorrhage pattern. The goal of this article is to enrich the clinical armamentarium of the neuroscience nurse, provide a comprehensive overview of nonaneurysmal SAH, and enhance patient and family education.