Introduction: Most cases of spontaneous subarachnoid hemorrhage (SAH) result from a ruptured intracranial aneurysm. Other causes of SAH include vascular malformations, tumors, arterial dissections, and coagulopathies, while a small percentage of patients have cryptogenic SAH. The use of anticoagulants or the presence of coagulopathies has been shown to increase the risk of intracranial hemorrhage and have been associated with poorer outcomes in patients with subarachnoid hemorrhage. A unique dilemma occurs when patients with coagulopathies are found to have an intracranial aneurysm that may not have been the cause of SAH.
Methods: We describe the clinical course of three spontaneous SAH in the setting of coagulopathies. A review of each patient’s medical record and imaging studies was completed.
Results: Three patients were identified. Two patients were anticoagulated for prothrombotic disorders, and one patient had Hemophilia A. Coagulopathies were corrected in each patient. Workup revealed a small aneurysm in each patient that appeared to be remote from the focus of SAH. Two patients underwent craniotomy and successful clipping of their aneurysms. Both aneurysms were unruptured on direct microsurgical inspection. The third patient had a small PCoA aneurysm that was not treated. All three patients had benign clinical courses with rapid resolution of the initial presenting symptoms and were discharged without neurological deficits.
Conclusions: In some patients, spontaneous SAH may be due to coagulopathy even if an aneurysm is discovered during the evaluation. The location of the aneurysm, the pattern of SAH on computed tomographic scans, and the clinical course are important to correlate in this patient population. In cases where there is sufficient doubt, the aneurysm should still be treated. If the clinical findings do not support an aneurysmal SAH, then treatment of the aneurysm is not mandatory. The clinical suspicion and the risk of treatment must be balanced in these unusual cases.
Patient Care: This series provides examples of nonaneurysmal causes of subarachnoid hemorrhage which should be considered before treating a patient with a coagulopathy and subarachnoid hemorrhage.
Learning Objectives: By the conclusion of this session, participants should be able to 1) List causes of subarachnoid hemorrhage, 2) Identify difficulties in treating coagulopathic patients